Trace element compositions, methods of making and use

ABSTRACT

Injectable compositions that can be added to parenteral nutrition are provided. In particular, a stable injectable composition is provided which includes water, and at least one of about 800 μg to about 4,000 μg of zinc, about 40 μg to about 400 μg of copper, from about 4 μg to about 90 μg of selenium, or from about 1 μg to about 80 μg of manganese per 1 mL of the injectable composition. Methods of preparing and using of the stable injectable composition are also provided.

This application claims priority to U.S. Provisional Application Ser.No. 63/047,708, filed on Jul. 2, 2020, the entire disclosure of which ishereby incorporated by reference in its entirety into the presentdisclosure.

BACKGROUND

Parenteral nutrition (PN) provides nutrients and fluids to a patient andis typically administered intravenously. It differs from normal oralfood ingestion in that the nutrients and fluids are administered by anintravenous infusion. In this way, the entire digestive tract isbypassed. Parenteral nutrition is indicated when ingestion ofnourishment administered orally via the digestive tract is not possible,not desired, or too dangerous. Thus, parenteral nutrition is used whenthere are considerable impediments in digestion and resorption, as wellas in the framework of intensive care medicine. Complete parenteralnutrition can supply the same nutrients as normal enteral nourishmentwhich includes carbohydrates, fats, proteins, vitamins, electrolytes,water and also trace elements (e.g., trace metals).

Trace elements together with vitamins are required for specificmetabolic functions. Trace elements are present at very lowconcentrations in the human body and help maintain physical and mentalhealth. As structural and/or functional constituents of numerousmetalloproteinases (e.g., copper, zinc), enzymes (e.g., selenium),hormones (e.g., iodine) or vitamins (e.g., cobalt), trace elements areinvolved in many metabolic processes. A deficiency of trace elementsimpairs the optimal development of important physiological processes inthe body.

Often times, one or more trace elements are added to the parenteralnutrition using specific pharmaceutical manufacturing regulations understrict aseptic conditions. Trace element addition to the parenteralnutrition is an important component in the framework of parenteralnutrition therapy. Trace element addition can also remedy an alreadyexisting trace element deficiency to help the patient have an enhancedquality of life. Although trace element addition facilitates manyenzymatic processes, long term use may cause accumulation of largequantities resulting in toxicity.

In recent years, recommended daily doses of trace elements (e.g.,copper, manganese, and chromium) have been reduced and some instancesdaily doses of chromium are not typically needed. Sometimes, the dailydosage of trace elements needs to be adjusted for contaminants that mayalready be present in the parenteral nutrition.

Because multiple trace elements (e.g., zinc, copper, selenium,manganese, and chromium) are currently available in all-in-oneformulations at higher daily doses, one or more trace elements are noteasily customizable to the patient's specific trace element requirementwhen it is added to the parenteral nutrition.

Typically, parenteral nutrition once admixed remains stable for arelatively short period of time without the addition of trace elementsto the parenteral nutrition. For example, once admixed, KABIVEN®parenteral nutrition remains stable for 48 hours at room temperature or25° C. This stability is without the addition of trace elements to theparenteral nutrition. If not used immediately, the admixed KABIVEN®parenteral nutrition can be stored for up to 7 days under refrigerationat 2° C. to 8° C. without the addition of trace elements to theparenteral nutrition. After removal from refrigeration, the admixedKABIVEN® parenteral nutrition should be used within 48 hours. If not, itshould be discarded. This type of stability is also for other differentbrands of parenteral nutrition.

Parenteral nutrition is admixed based on the specific metabolic needs ofthe patient. Admixing parenteral nutrition can be time consuming,expensive, and tedious to prepare under aseptic conditions. Often whentrace elements are added to parenteral nutrition and the parenteralnutrition is stored for more than 24 to 48 hours at room temperature,stability problems such as, for example, particulate formation andprecipitation may occur. This requires the healthcare provider (e.g.,pharmacist, nurse, healthcare facility, caregiver, etc.) to dispose ofany unused parenteral nutrition after the 24 to 48-hour time period,which increases cost to the patient and the healthcare provider.

Further, if the patient's parenteral nutrition is put on hold for ashort period of time (e.g., 48 hours); the admixed parenteral nutritioncontaining the added trace elements will also need to be discarded. Thiscan lead to drug supply shortages as now the parenteral nutrition andtrace elements have to be discarded and a new prescription of parenteralnutrition containing the trace elements has to be admixed again. Becauseof the short stability period, parenteral nutrition with added traceelements is prepared close to the time period that it will beadministered to the patient on a daily basis, which may require frequenttrips to the healthcare facility. This also prevents the parenteralnutrition with added trace elements to be made in many daily doses or inbatches.

Thus, there is a need for injectable parenteral nutrition containing oneor more trace elements that is stable for a longer period of time,thereby reducing the time and costs associated with frequent admixing.The quality of life of the patient and the caregiver is also improved byavoiding frequent trips to healthcare facilities for the admixing ofinjectable parenteral nutrition. Further, there is also a need forparenteral nutrition with one or more added trace elements that can bemade in many daily doses or in batches because it is stable for a longerperiod of time. There is also a need for trace element compositions andmethods that have lower daily doses of one or more trace elementscompared to those in currently available trace element products.

SUMMARY

An injectable parenteral nutrition containing a trace element isprovided that is stable for a longer period of time compared to existingparenteral nutrition products that have trace elements added thereto,thereby reducing the time and costs associated with frequent admixing.The quality of life of the patient and the caregiver is also improved byavoiding frequent trips to healthcare facilities for the admixing ofinjectable parenteral nutrition. An injectable parenteral nutritioncontaining a trace element is also provided that can be made in dailydoses or in batches because it is stable for a longer period of time.There is also provided a trace element composition and method that havelower daily doses of one or more trace elements as compared to currentlyavailable trace element products (e.g., Mutitrace-5® concentrate,Addamel™) that can be dosed for adult, pediatric or neonatal patients.

In one embodiment there is an injectable composition comprising water,and at least one of about 800 μg to about 4,000 μg of zinc, about 40 μgto about 400 μg of copper, about 4 μg to about 90 μg of selenium, orabout 1 μg to about 80 μg of manganese per 1 mL of the injectablecomposition.

In another embodiment, there is an injectable composition comprisingwater, and at least one trace element consisting of about 800 μg toabout 4,000 μg of zinc, about 40 μg to about 400 μg of copper, about 4μg to about 90 μg of selenium, or about 1 μg to about 80 μg of manganeseper 1 mL of the injectable composition.

In yet another embodiment, there is a method of making an injectablecomposition, the method comprising mixing at least one of about 800 μgto about 4,000 μg of zinc, about 40 μg to about 400 μg of copper, about4 μg to about 90 μg of selenium, or about 1 μg to about 80 μg ofmanganese with water to form 1 mL of the injectable composition.

In still yet another embodiment, there is a method of maintaining plasmatrace elements in a patient in need thereof, the method comprisingadministering at least an injectable composition to the patient, theinjectable composition comprising water, and at least one of about 800μg to about 4,000 μg of zinc, about 40 μg to about 400 μg of copper,about 4 μg to about 90 μg of selenium, or about 1 μg to about 80 μg ofmanganese per 1 mL of the injectable composition.

In one exemplary embodiment, there is an injectable trace elementcomposition comprising water, and at least one of about 800 μg to about4,000 μg of zinc, about 40 μg to about 400 μg of copper, about 4 μg toabout 90 μg of selenium, or about 1 μg to about 80 μg of manganese per 1mL of the injectable composition.

In various embodiments, the injectable compositions described in thisapplication comprise, consist essentially of or consist of water, atleast one of zinc in an amount from about 600 ug, 700 ug, or 800 μg toabout 4,000 μg, copper in an amount from about 40 μg to about 400 μg,from about 4 μg to about 90 μg of selenium, and from about 1 μg to about80 μg of manganese per 1 mL of the injectable composition.

Stable trace element injectable compositions or injectable compositionsthat can be added to a parenteral nutrition are provided. In variousaspects, a stable injectable composition comprises water, from about 800μg to about 4,000 μg of zinc, from about 40 μg to about 400 μg ofcopper, from about 4 μg to about 90 μg of selenium, and from about 1 μgto about 80 μg of manganese per 1 mL of the injectable. In some aspects,the stable trace element injectable composition consists essentially ofor consists of water, from about 900 μg to about 4,000 μg of zinc, fromabout 40 μg to about 400 μg of copper, from about 4 μg to about 90 μg ofselenium, and from about 1 μg to about 80 μg of manganese per 1 mL ofthe injectable.

In some embodiments, methods of making and using the stable injectablecompositions of this application are provided. In one aspect, the methodof making a trace element injectable composition includes mixing fromabout 800 μg to about 4,000 μg of zinc, from about 40 μg to about 400 μgof copper, about 4 μg to about 90 μg of selenium, and about 1 μg toabout 80 μg of manganese with water to form 1 mL of the injectablecomposition.

In some embodiments, there is a method of maintaining plasma traceelements in a patient in need thereof, the method includingadministering at least an injectable composition to the patient, theinjectable composition comprising water, from about 800 μg to about4,000 μg of zinc, from about 40 μg to about 400 μg of copper, from about4 μg to about 90 μg of selenium, and from about 1 μg to about 80 μg ofmanganese per 1 mL of the injectable composition.

In various aspects, stable parenteral nutrition is provided comprisingat least one of an amino acid, a dextrose, a lipid, water, anelectrolyte, or a mixture thereof and at least one trace element whichis stable for about at least 3 days to about 14 days. In variousembodiments, the at least one trace element of the stable parenteralnutrition includes zinc, copper, selenium, and manganese or a mixturethereof.

In many embodiments, parenteral nutrition comprises, consistsessentially of, or consists of an amino acid, a dextrose, a lipid, anelectrolyte, or a mixture thereof and at least one trace elementcomposition per from about 250 mL to about 4000 mL of parenteralnutrition. The stable trace element injectable composition that can beadded to a parenteral nutrition comprises, consists essentially of orconsists of water, from about 800 μg to about 4,000 μg of zinc, fromabout 40 μg to about 400 μg of copper, from about 4 μg to about 90 μg ofselenium, and from about 1 μg to about 80 μg of manganese per 1 mL ofthe injectable. In some embodiments, the trace element injectablecomposition that can be added to parenteral nutrition contains water forinjection and trace elements comprising, consisting essentially of orconsisting of from about 2000 μg to about 4,000 μg of zinc, from about200 μg to about 400 μg of copper, from about 30 μg to about 90 μg ofselenium and from about 20 μg to about 80 μg of manganese per 1 mL ofthe injectable composition.

In some embodiments, the trace element injectable composition comprises,consists essentially of, or consists of 3,000 μg of zinc, 300 μg ofcopper, 60 μg of selenium, and 55 μg of manganese per 1 mL of theinjectable composition. These trace element compositions are usefuladditives to parenteral nutrition for adult or pediatric patients.

In yet other embodiments, the stable trace element composition that canbe added to parenteral nutrition comprises, consists essentially of orconsists of 1000 μg of zinc, 60 μg of copper, 6 μg of selenium and 3 μgof manganese per 1 mL of the injectable composition. These trace elementcompositions are useful additives to parenteral nutrition for neonatepatients.

In various embodiments, the injectable compositions including traceelements can be added to parenteral nutrition available in themarketplace, for example KABIVEN® and CLINIMIX®. As a result, thisapplication provides parenteral nutrition comprising at least one of anamino acid, a dextrose, a lipid, an electrolyte or a mixture thereof andat least one of zinc, copper, selenium, and manganese, which is stablefor about at least 3 days to about 14 days.

In some embodiments, there is a method of making a parenteral nutritioncontaining trace elements, the method comprising adding trace elementsto the parenteral nutrition, the trace elements comprising about 800 μgto about 4,000 μg of zinc, about 40 μg to about 400 μg of copper, about4 μg to about 90 μg of selenium, and about 1 μg to about 80 μg ofmanganese per 250 mL to about 4000 mL of the parenteral nutrition, theparenteral nutrition comprising at least one of amino acid, a dextrose,a lipid, an electrolyte, or a mixture thereof.

In some aspects, there is a method of providing a source of calories,protein, electrolytes, water or essential fatty acids for adult,pediatric or neonate patients requiring parenteral nutrition, the methodcomprising administering to a patient in need thereof an injectableparenteral nutrition formulation comprising at least one of an aminoacid, a dextrose, a lipid, an electrolyte, or a mixture thereof, theparenteral nutrition comprising about 800 μg to about 4,000 μg of zinc,about 40 μg to about 400 μg of copper, about 4 μg to about 90 μg ofselenium, and about 1 μg to about 80 μg of manganese per 250 mL to 4000mL of the parenteral nutrition.

In some embodiments, there is a method of maintaining plasma traceelements in a patient in need thereof, the method comprisingadministering a parenteral nutrition to the patient, the parenteralnutrition comprising at least one of an amino acid, a dextrose, a lipid,an electrolyte or a mixture thereof and at least one of zinc, copper,selenium, and manganese, which is stable for about at least 3 days toabout 14 days to prevent depletion of endogenous stores of the at leastone of zinc, copper, selenium, and manganese and subsequent depletionsymptoms.

A method of maintaining, supplementing or increasing one or more traceelements to a patient in need thereof, the method comprisingadministering to the patient about 800 μg to about 4,000 μg of zinc,about 40 μg to about 400 μg of copper, about 4 μg to about 90 μg ofselenium, or about 1 μg to about 80 μg of manganese per about 250 mL to4000 mL of aqueous fluid, the aqueous fluid comprising an amino acid, adextrose, a lipid, an electrolyte or a mixture thereof.

Additional features and advantages of various embodiments will be setforth in part in the description that follows, and in part will beapparent from the description, or may be learned by practice of variousembodiments. The objectives and other advantages of various embodimentswill be realized and attained by means of the elements and combinationsparticularly pointed out in the description and appended claims.

DETAILED DESCRIPTION

Definitions

For the purposes of this specification and appended claims, unlessotherwise indicated, all numbers expressing quantities of ingredients,percentages or proportions of materials, reaction conditions, and othernumerical values used in the specification and claims, are to beunderstood as being modified in all instances by the term “about.”Accordingly, unless indicated to the contrary, the numerical parametersset forth in the following specification and attached claims areapproximations that may vary depending upon the desired propertiessought to be obtained by the present disclosure. At the very least, andnot as an attempt to limit the application of the doctrine ofequivalents to the scope of the claims, each numerical parameter shouldat least be construed in light of the number of reported significantdigits and by applying ordinary rounding techniques.

Notwithstanding that the numerical ranges and parameters setting forththe broad scope of the disclosure are approximations, the numericalvalues set forth in the specific examples are reported as precisely aspossible. Any numerical value, however, inherently contains certainerrors necessarily resulting from the standard deviation found in theirrespective testing measurements. Moreover, all ranges disclosed hereinare to be understood to encompass any and all subranges subsumedtherein. For example, a range of “1 to 10” includes any and allsubranges between (and including) the minimum value of 1 and the maximumvalue of 10, that is, any and all subranges having a minimum value ofequal to or greater than 1 and a maximum value of equal to or less than10, e.g., 5.5 to 10.

Scientific and technical terms used herein have meanings commonly usedin the art unless otherwise specified. The definitions provided hereinare to facilitate understanding of certain terms used frequently hereinand are not meant to limit the scope of the present disclosure.

It is noted that, as used in this specification and the appended claims,the singular forms “a,” “an,” and “the,” include plural referents unlessexpressly and unequivocally limited to one referent. Thus, for example,reference to “a trace element” includes one, two, three or more traceelements.

As used in this specification and the appended claims, the term “or” isgenerally employed in its sense including “and/or” unless the contentclearly dictates otherwise.

Patents, patent applications, published applications and publications,websites and other published materials referred to throughout the entiredisclosure herein, unless noted otherwise, are incorporated by referencein their entirety. In the event that there are a plurality ofdefinitions for terms herein, those in this section prevail. Wherereference is made to a URL or other such identifier or address, it isunderstood that such identifiers can change and particular informationon the internet can come and go, but equivalent information can be foundby searching the internet. Reference thereto evidences the availabilityand public dissemination of such information.

The term “composition(s)” refers to an aggregate material formed fromtwo or more substances, ingredients, or constituents; the way in which awhole or mixture is made up. When referring to pharmaceutical drugproducts, a composition is often called “formulation(s)”.

The term “impurity” refers to a constituent, component or ingredientwhich impairs the purity of a pharmaceutical active ingredient orpharmaceutical composition.

The term “injectable” or “injectable composition,” as used herein, meansa composition that can be injected into a larger volume container andinfused intravenously via peripheral veins found in upper extremities(hands and arms) or central veins, which is a large vein in the centralcirculation system. Catheters are used to reach either a peripheral orcentral vein. For example, central venous catheters can be insertedpercutaneously or surgically through the jugular, subclavian, or femoralveins, or via the chest or upper arm peripheral veins.

The trace elements composition can be administered parenterallyincluding intravenously or the like into the patient (e.g., mammal). Theterm “mammal” refers to organisms from the taxonomy class “mammalian,”including but not limited to humans, other primates such as monkeys,chimpanzees, apes, orangutans and monkeys, rats, mice, rabbits, cats,dogs, pigs, cows, horses, etc.

The term “reference listed drug” refers to an approved drug product towhich generic versions are compared to show that they are bioequivalent.

The term “stability” refers to capability of a pharmaceutical activeingredient or pharmaceutical composition to remain within a specificcriteria or specification(s).

The term “stable”, as used herein, means remaining in a state orcondition that is suitable for administration to a patient and withoutundergoing a substantial change in the potency of the active agent inthe formulation over the specified time period. In some embodiments, theinjectable parenteral nutrition composition containing trace elements ofthe current application is considered stable if the parenteral nutritioncomposition containing trace elements can maintain its strength at thelevel specified on the label for the maximum anticipated shelf-life(e.g., the time period from the date of manufacture until administrationto the animal, for example, a human patient) under environmentalconditions likely to be encountered in actual use. Typically, stabilitycan be determined following the FDA guidelines, for example, Guidancefor Industry: Drug Stability Guidelines (p. 1-48), Dec. 9, 2008.

A substantial change in potency is one which decreases the drugconcentration by more than 15%, from the target concentration for thespecified period of time. Unless indicated otherwise, a stablecomposition is one which retains at least 85% of the original amount ofthe injectable composition in that state (e.g., not precipitated,degraded, or adsorbed to the container) for a period of at least 72hours.

The carriers and excipients and other components of the pharmaceuticalcompositions must be “pharmaceutically acceptable” in the sense of beingcompatible with the other ingredients of the formulation and notdeleterious to the recipient thereof. Thus, the term “pharmaceuticallyacceptable salt” references salt forms of the active compounds which areprepared with counter ions which are non-toxic under the conditions ofuse and are compatible with a stable formulation. For compounds whichcontain relatively acidic functionalities, base addition salts can beobtained by contacting the neutral form of such compounds with asufficient amount of the desired base, either neat or in a suitableinert solvent.

The term “pharmaceutically acceptable carrier or excipient” means acarrier or excipient that is useful in preparing a pharmaceuticalcomposition that has an acceptable side-effect profile and serves toprovide a medium for the storage or administration of the activecomponent(s) under the conditions of administration for which thecomposition is formulated or used. The carrier or excipient iscompatible with the other ingredients of the formulation and notdeleterious to the recipient thereof. A “pharmaceutically acceptablecarrier or excipient” as used in the specification and claims includesboth one and more than one such carrier or excipient. Pharmaceuticallyacceptable carriers are determined in part by the particular compositionbeing administered, as well as by the particular method used toadminister the composition. For the injectable compositions of thisdisclosure, water is a pharmaceutically acceptable carrier. There are awide variety of suitable formulations of pharmaceutical compositions ofthe present disclosure (see, e.g., Remington's Pharmaceutical Sciences,20th ed., 2018, supra).

The term “tonicity adjusting agents” refers to agents used to modify theosmolality of a formulation to bring it closer to the osmotic pressureof body fluids such as blood or plasma. Provided that the compositionsare physiologically compatible, the compositions do not require anyparticular osmolality. Thus, the compositions can be hypotonic,isotonic, or hypertonic. Typically, the pharmaceutical compositions havean osmolality between about 250 to 350 mOsm/kg. The tonicity of thepharmaceutical compositions can be adjusted by adjusting theconcentration of any one or more of a tonicity agent, a co-solvent,complexing agent, buffering agent, or excipient. Suitable tonicityadjusting agents include, but are not limited to, anhydrous and hydrousforms of dextrose, for example, dextrose 5%, dextrose 10%, dextrose 20%,dextrose 25%, or dextrose 50% in water or a combination thereof.

The pH of the injectable composition can be adjusted to the recited pHrange or target pH by the addition of an acid or acidic salt or base orbasic salt, as appropriate. For instance, the pH may be adjusted with abase such as an alkali metal hydroxide such as NaOH, KOH, or LiOH, or analkaline earth metal hydroxide, such as Mg(OH)2 or Ca(OH)2, or acarbonate. Acids useful for adjusting the pH include, withoutlimitation, hydrochloric acid, or sulfuric acid, for example.

The term “pharmaceutical composition” is intended to encompass a productcomprising the active ingredient(s), and the inert ingredient(s) thatmake up the carrier, as well as any product which results, directly orindirectly, from combination, complexation or aggregation of any two ormore of the ingredients, or from dissociation of one or more of theingredients, or from other types of reactions or interactions of one ormore of the ingredients described herein.

The term “single-use container” refers to a sealed pharmaceuticallyprepared container holding a drug product in a sterile environment thatis intended to be used in a single operation of transferring the entirecontents or substantially entire contents. It should be recognized thatthe single-use container is generally preservative-free and that ifmultiple transfers are attempted, they should be completed in a shortduration, i.e., less than about 8-10 hours from the first breach of thesterile environment. In some aspects the single-use container may beused to administer all of its contents to one subject in need thereof.In some aspects the single-use container may be used to administer itscontents to more than one subject in need thereof.

As used herein, the term “mixing” refers to admixing, contacting,blending, stirring, or allowing to admix, mix, blend, stir and the like.

The term “dissolved oxygen” refers to oxygen that is found in theaqueous carrier of the compositions. Distinguished from dissolved oxygenis the headspace oxygen. As used herein, the term “headspace oxygen”refers to the oxygen that is found in the headspace volume of the sealedcontainer comprising the composition.

It will be apparent to those skilled in the art that variousmodifications and variations can be made to various embodimentsdescribed herein without departing from the spirit or scope of theteachings herein. Thus, it is intended that various embodiments coverother modifications and variations of various embodiments within thescope of the present teachings.

The headings below are not meant to limit the disclosure in any way;embodiments under anyone heading may be used in conjunction withembodiments under any other heading.

Trace Elements Injectable Compositions

This application relates to the development of injectable compositionscomprising at least one of zinc, copper, manganese, and selenium. Theinjectable compositions of this application include lower daily amountsof at least one of zinc, copper, manganese, chromium, or selenium per 1mL of the composition than currently available products.

Trace elements, such as zinc, copper, manganese, and selenium areimportant to metabolic functions and for restoring and maintainingnormal growth and development in mammals. Zinc is a trace element. Zincis a constituent of numerous enzymes including carbonic anhydrase,alcohol and lactate dehydrogenases and various peptidases. Zinc has beenidentified as a cofactor for over 70 different enzymes, includingalkaline phosphatase, lactic dehydrogenase and both RNA and DNApolymerase. Zinc facilitates wound healing, helps maintain normal growthrates, normal skin hydration and the senses of taste and smell. Zinc isconsidered an essential nutrient participating in multiplemetalloenzymes involved in most central metabolic pathways, includingmetabolism of protein, fat, and carbohydrates; DNA binding; generegulation; transcription of DNA to RNA; synthesis of heme, long-chainfatty acids, and prostaglandins; cholesterol transport; stabilization ofcell membrane lipids; sexual maturation and reproduction; and immunefunction.

Copper is a trace element. Copper is essential as a cofactor for serumceruloplasmin, an oxidase necessary for proper formation of the ironcarrier protein, transferrin. Copper also helps maintain normal rates ofred and white blood cell formation. The metabolic functions of copperrelate to its presence in tyrosinase, urate oxidase,dopamine-β-hydroxylase, amine oxidases, cytochrome oxidase andcytoplasmic superoxide dismutase, in the latter, in combination withzinc. Copper is incorporated into metalloenzymes that are involved withconnective tissue formation; metabolism of iron (ceruloplasmin),cholesterol, and glucose; myelin synthesis; conversion of dopamine tonorepinephrine in the brain, serotonin synthesis, melanin pigmentformation; and antioxidant participating in the immune system.

Manganese is another trace element. Manganese is believed to have anactivating function for many enzymes such as phosphoglucomutase, cholineesterase, the oxidative β-keto-decarboxylases, certain peptidases, andmuscle ATPase. Manganese is an activator for enzymes such aspolysaccharide polymerase, liver arginase, cholinesterase, and pyruvatecarboxylase. Manganese is incorporated into metalloenzymes involved withenergy release, fatty acid and cholesterol synthesis, and release oflipids from the liver.

Selenium is also a trace element. Selenium is part of glutathioneperoxidase which protects cell components from oxidative damage due toperoxides produced in cellular metabolism. Selenium is incorporated atthe active site of glutathione peroxidase, an enzyme that catalyzes thebreakdown of hydroperoxides and has metabolic interrelationships withvitamin E, an antioxidant (Vanek et al., A.S.P.E.N. Position Paper,Nutrition in Clinical Practice, Vol. 27, No. 4, pp. 440-491, August2012).

In various embodiments, the injectable compositions described in thisapplication comprise, consist essentially of or consist of water, atleast one of zinc in an amount from about 900 μg to about 4,000 μg,copper in an amount from about 40 μg to about 400 μg, selenium in anamount from about 4 μg to about 90 μg, or manganese in an amount formabout 1 μg to about 80 μg per 1 mL of the injectable composition.Therefore, the injectable composition, in some embodiments, can have asthe trace element zinc only, copper only, selenium only, manganese onlyor they can be in the composition in any combination.

In some embodiments, the injectable compositions described in thisapplication comprise water, and at least one of zinc in an amount fromabout 2000 μg to about 4,000 μg, copper in an amount from about 200 μgto about 400 μg, about 30 μg to about 90 μg of selenium, and about 20 μgto about 80 μg of manganese per 1 mL of the injectable composition. Insome other embodiments, zinc is in an amount from about 900 μg, 1000,1100, 1200, 1300, 1400, 1500, 1600, 1700, 1800, 1900, 2000, 2100, 2200,2300, 2400, 2500, 2600, 2700, 2800, 2900, 3000, 3100, 3200, 3300, 3400,3500, 3600, 3700, 3800, 3900 to about 4000 μg. In various embodiments,copper is in an amount from about 40 μg, 50, 60, 70, 80, 90, 100, 110,120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250,260, 270, 280, 290, 300, 310, 320, 330, 340, 350, 360, 370, 380, 390 toabout 400 μg. In other embodiments, selenium is in an amount from about4 μg, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70, 80 to about 90 μg. Inyet other embodiments, manganese is in an amount from about 1 μg, 2, 3,4, 5, 6, 7, 8, 9, 10, 20, 30, 40, 50, 60, 70 to about 80 μg. In variousembodiments, the injectable compositions described in this applicationcomprise, consist essentially of or consist of water, zinc in an amountfrom about 2000 μg to about 4,000 μg, copper in an amount from about 200μg to about 400 μg, about 30 μg to about 90 μg of selenium, and about 20μg to about 80 μg of manganese per 1 mL of the injectable composition.

In some embodiments, the injectable composition comprises water, and atleast one of 3,000 μg of zinc, 300 μg of copper, 60 μg of selenium, and55 μg of manganese per 1 mL of the injectable composition. In otherembodiments, the injectable composition consists essentially of orconsists of water, 3,000 μg of zinc, 300 μg of copper, 60 μg ofselenium, and 55 μg of manganese per 1 mL of the injectable composition.These embodiments are useful as additives to parenteral nutritionapplicable to adults or pediatric patients.

In other embodiments, the injectable composition comprises water 1000 μgof zinc, 60 μg of copper, 6 μg of selenium and 3 μg of manganese perabout 250 mL to 4000 mL of parenteral nutrition. In yet otherembodiments, the trace element injectable composition consistessentially of or consists of water, 1000 μg of zinc, 60 μg of copper, 6μg of selenium and 3 μg of manganese per about 250 mL to 4000 mL ofparenteral nutrition. These embodiments are useful as additives toparenteral nutrition applicable to neonate patients.

In various aspects the injectable composition includes only one of thetrace elements, for example only zinc or copper, or manganese orselenium. The at least one of the zinc can include from about 0.23 wt.percent to about 1.33 wt. percent. The at least one of copper can be inan amount from about 0.03 wt. percent to about 0.13 wt. percent. The atleast one of manganese comprises from about 0.0055 wt. percent to about0.013 wt. percent. The at least one of selenium comprises about 0.002wt. percent to about 0.02 wt. percent and the water comprises from about96 wt. percent to about 99.66 wt. percent of the injectable compositionbased on a total weight of the injectable composition. In yet otherembodiments, at least one of the zinc comprises about 0.3 wt. percent,the copper comprises about 0.03 wt. percent, the manganese comprisesabout 0.0055 wt. percent, the selenium comprises about 0.006 wt.percent, or the water comprises from about 99.66 wt. percent of theinjectable composition based on a total weight of the injectablecomposition.

In many aspects, the zinc in the injectable composition is elementalzinc, the copper is elemental copper, the selenium is elementalselenium, the manganese is elemental manganese and the water is sterilewater for injection. In other instances, the elemental zinc is obtainedfrom zinc sulfate or zinc sulfate heptahydrate, the elemental copper isgenerated from cupric sulfate or cupric sulfate pentahydrate, theelemental manganese is from manganese sulfate or manganese sulfatemonohydrate and the elemental selenium is obtained from selenious acid.The injectable composition described in this application contains, insome aspects, zinc obtained from zinc sulfate heptahydrate, wherein thezinc and is at a dose of from about 2.5 to about 7 mg/day. The copper ofthe injectable composition can be obtained from cupric sulfatepentahydrate and is at a dose of from about 0.3 to about 1.5 mg/day, themanganese is manganese sulfate monohydrate and is at a dose of about0.015 to about 0.08 mg/day, and the selenium is obtained from seleniousacid and is at a dose of from about 20 to about 60 μg/day. In otheraspects, the injectable composition contains zinc from zinc sulfateheptahydrate, wherein the zinc is at a dose of from about 2.5 to about 7mg/day, the copper is obtained from cupric sulfate pentahydrate and isat a dose of from about 0.5 to about 1.5 mg/day, the manganese isobtained from manganese sulfate monohydrate and is at a dose of fromabout 0.15 to about 0.8 mg/day, and the selenium is obtained fromselenious acid and is at a dose of about 20 to about 40 μg/day.

In various aspects, the trace elements of the compositions of thisapplication comprise, consist essentially of or consist of zinc sulfateor zinc sulfate heptahydrate in an amount of from about 13.1 mg (13000μg) to about 13.3 mg, cupric sulfate or cupric sulfate pentahydrate inan amount of about 1.1 mg to about 1.2 mg, manganese sulfate ormanganese sulfate monohydrate in an amount of about 0.16 mg to about0.18 mg and selenious acid in an amount of about 95 μg to about 99 μgper 1 mL of the injectable composition. In other aspects, in theinjectable compositions, the trace elements comprise, consistessentially of or consist of zinc sulfate or zinc sulfate heptahydratein an amount of from about 13.1 mg (13000 μg) to about 13.3 mg, cupricsulfate or cupric sulfate pentahydrate in an amount of from about 1.1 mgto about 1.2 mg, manganese sulfate or manganese sulfate monohydrate inan amount of from about 0.016 mg to about 0.018 mg and selenious acid inan amount of from about 95 μg to about 99 μg per 1 mL of the injectablecomposition. In yet other aspects, the zinc sulfate or zinc sulfateheptahydrate is in an amount of about 13.2 mg, the cupric sulfate or thecupric sulfate pentahydrate is in an amount of about 1.179 mg, themanganese sulfate or manganese sulfate monohydrate is in an amount ofabout 0.169 mg and the selenious acid is in an amount of about 98 μg per1 mL of the injectable composition.

Zinc Sulfate heptahydrate is available from Avantor PerformanceMaterials, LLC in Phillipsburg, N.J. Cupric sulfate pentahydrate USP canbe obtained from Merck KGaA in Germany. Manganese sulfate monohydrate isavailable from Merck KGa in Germany. Selenious acid is available fromSigma Aldrich.

The trace elements composition can be added to one of an amino acid, adextrose, a lipid, an electrolyte or a mixture thereof and administeredto the patient parenterally (e.g., intravenously). Typically, the traceelements composition can be administered by intravenous infusion. Forexample, the trace elements composition can be added to parenteralnutrition and administered intravenously where about 100 mL to 4000 mLcan be administered via IV infusion over, for example, about 4 hours to24 hours, or about 8 hours to 48 hours to the patient.

One embodiment of the trace elements injectable composition of thisapplication useful for adult or pediatric patients is summarized inTable 1.

TABLE 1 Injectable Composition Ingredient (Name and Quality QuantityElemental Standard) Function per mL % w/v Equivalent Zinc Sulfate•7H₂O,Active 13.20 mg  1.320%   3 mg Zn/mL USP Cupric Active 1.18 mg  0.118%0.3 mg Cu/mL Sulfate•5H₂O, USP Manganese Active 169 mcg  0.017%  55 μgMn/mL Sulfate•H₂O, USP Selenious Acid, Active 98 mcg  0.010%  60 μgSe/mL USP Sulfuric Acid, NF pH N/A N/A N/A adjust- ment Water forInjection, Solvent q.s. to 98.535% N/A USP 1 mL N/A refers to notapplicable; USP refers to United States Pharmacopeia; NF refers toNational Formulary.Elemental Impurities of Trace Elements Injectable Composition

The trace elements injectable composition, USP is a compendial drugproduct. Consequently, the characteristics of the injectable compositionare based on the drug product release specifications established by thecompendial monograph for the product, FDA guidance, and theInternational Council for Harmonization of Technical Requirements forPharmaceuticals for Human Use (ICH) recommendations. The drug productrelease specifications, which include all critical drug productattributes, are illustrated in Table 2.

TABLE 2 Specifications and Properties of Trace Elements InjectableComposition Properties Target Justification Description Clear,colorless, to slightly blue solution Based on accumulated data and asand is essentially free from visible per current USP <1>. particulates.Identification A. Zinc-The Assay preparation, prepared In accordancewith proposed USP as directed in the Assay, exhibits an monograph forTrace Elements emission maximum at 472.215 nm when InjectableComposition and ICH tested as directed for Procedure in the requirementsfor identification respective Assay. tests. B. Copper-The Assaypreparation, prepared as directed in the Assay, exhibits an emissionmaximum at 224.700 nm when tested as directed for Procedure in therespective Assay. C. Selenium-The Assay preparation, prepared asdirected in the Assay, exhibits an emission maximum at 196.026 nm whentested as directed for Procedure in the respective Assay. D.Manganese-The Assay preparation, prepared as directed in the Assay,exhibits an emission maximum at 279.827 nm when tested as directed forProcedure in the respective Assay. pH Between 1.5 and 3.5 In accordancewith proposed USP monograph for Trace Elements Injectable Compositionand ICH requirements for identification tests. Residual MeetsRequirements under Option 2. As per USP <467> and ICH Q3C. SolventsAssay Zinc: 90.0%-110.0% Label Claim (L.C. = 3 mg/mL of Zinc) Copper:90.0%-110.0% Label Claim (L.C. = 0.3 mg/mL of Coper) Selenium:90.0%-110.0% Label Claim (L.C. = 60 μg/mL of Selenium) Manganese:90.0%-110.0% Label Claim (L.C. = 55 μg/mL of Manganese) Volume of 1 mLfill: the volume is not less than the As per USP <1151>. Solutionlabeled volume of 1 mL. Aluminum Not more than 6,000 μg/L As per 21 CFR201.323, USP <7>, and FDA recommendation for the limit of not more than0.6 μg/kg/day. Elemental Meets requirements As per ICH Q3D and USP <232>Impurities Cadmium (Cd): Not more than 0.4 for the intended dose volumeof 1 μg/mL mL/day for Adult and Pediatric Lead (Pb): Not more than 0.5μg/mL patients. Arsenic (As): Not more than 1.5 μg/mL Mercury (Hg): Notmore than 0.4 μg/mL Chromium (Cr): Not more than 1.0 μg/mL Iron (Fe):Not more than 10 μg/mL Boron (B): Not more than 50 μg/mL Calcium (Ca):Not more than 50 μg/mL Magnesium (Mg): Not more than 50 μg/mL Silicon(Si): Not more than 100 μg/mL Particulate NMT 6,000 particles ≥10 μm pervial As per USP <788>. Matter NMT 600 particles ≥25 μm per vial Ifretested by the Microscopic Method: NMT 3,000 particles ≥10 μm per vialNMT 300 particles ≥25 μm per vial Sterility If no growth is observed,the article As per USP <71>. tested meets the requirements of the testfor sterility. Bacterial The Endotoxin limit is not more than 50 As perUSP <85> and the maximum Endotoxins EU/mL daily dose of the drugproduct. Other It meets the requirements under Injections As per USP<1>. Requirements and Implanted Drug Products <1>.

While these injectable compositions contain little or no impurities, insome aspects, these compositions can include a chromium impurity in anamount not to exceed about 1 μg and, in other aspects, not to exceed 0.5μg. In other instances, the injectable composition contains from about0.0001 μg/mL to about 0.25 μg/mL of chromium. In many cases, theinjectable composition of this disclosure does not contain anydetectable chromium or no chromium at all.

In some embodiments, the chromium can be in the PN containing the traceelements composition or the trace elements composition itself in anamount of not more than about 0.15 μg/mL, 0.14 μg/mL, 0.13 μg/mL, 0.12μg/mL, 0.11 μg/mL, 0.10 μg/mL, 0.09 μg/mL, 0.08 μg/mL, 0.07 μg/mL, 0.06μg/mL, 0.05 μg/mL, 0.04 μg/mL, 0.03 μg/mL, 0.02 μg/mL to not more thanabout 0.01 μg/mL or lower. Therefore, in this embodiment, it isdesirable to have no or little chromium.

In various embodiments, other elemental impurities, for example, lead,arsenic, cadmium, mercury iron, chromium (potential manufacturingprocess contaminants) and boron, calcium, magnesium, and silicon(potential leachable elemental impurities from the drug product Type Iglass vials and West elastomeric formulation 4432/50 grey stopper usedas immediate packaging) have been considered.

Dosing recommendations for pediatric patients is based on body weightand ranges from about 0.2 mL to about 0.8 mL per day as shown in Table 3where MDD refers to maximum daily dose.

TABLE 3 Dosing Requirements in mL/kg Body Weight for Trace ElementCompositions MDD Patient Group Body Weight (mL) Adult ≥50 kg   1 mLPediatric 40 kg to 49 kg 0.8 mL Pediatric 30 kg to 39 kg 0.6 mLPediatric 20 kg to 29 kg 0.4 mL Pediatric 10 kg to 19 kg 0.2 mL

In some embodiments, the permitted daily limits (PDL) of the injectabletrace elements of the current application include, as little as possibleof cadmium, lead, arsenic, mercury, cobalt, vanadium, nickel, thallium,gold, palladium, iridium, osmium, rhodium, ruthenium, silver, platinum,lithium, antimony, barium, molybdenum, tin, chromium, aluminum, boron,calcium, iron, potassium, magnesium, sodium, tungsten, and/or silicon.

In some embodiments, the permitted daily limits (PDL) of the injectabletrace elements of the current application are not to exceed about 0.4μg/day of cadmium, about 0.5 μg/day of lead, about 1.5 μg/day ofarsenic, about 0.4 μg/day of mercury, about 1 μg/day of cobalt, about 2μg/day of vanadium, about 4 μg/day of nickel, about 1.6 μg/day ofthallium, about 20 μg/day of gold, about 2 μg/day of palladium, about 2μg/day of iridium, about 2 μg/day of osmium, about 2 μg/day of rhodium,about 2 μg/day of ruthenium, about 2 μg/day of silver, about 2 μg/day ofplatinum, about 50 μg/day of lithium, about 18 μg/day of antimony, about140 μg/day of barium, about 300 μg/day of molybdenum, about 120 μg/dayof tin, about 1 μg/day of chromium, about 6 μg/day of aluminum, about 50μg/day of boron, about 50 μg/day of calcium, about 10 μg/day of iron,about 94,000 μg/day of potassium, about 50 μg/day of magnesium, about24,000 μg/day of sodium, about 1 μg/day of tungsten, and/or about 100μg/day of silicon.

Permitted Daily Exposure (PDE) for pediatric patient groups werecalculated using the following equation: PDE (μg/day) for Pediatric=PDEper ICH (μg/day)/(50 kg)(10 kg).

Concentration limit for each element is based on PDE, the maximum dailyvolume, and ICH control threshold, defined as a level that is 30% of theestablished PDE in the drug product was calculated using the followingformulas:

Concentration Limit (μg/mL)=PDE (μg/Day)/Maximum Daily Volume (mL)

Control Threshold (μg/mL)=Concentration Limit (μg/mL)/100%-30%

A summary of PDEs, concentration limits, and 30% control thresholds forevaluated elements are provided in Table 4.

TABLE 4 Elemental Impurities Concentration Limits for Trace elementsinjectable composition, USP for Pediatric Patient Population PDEAmerican PDE Limit Concentration Regent Control Limit Pediatric LimitSpecification Threshold Element Class (μg/day) (μg/day) (μg/mL) (μg/mL)(μg/mL) Cd (Cadmium) 1 2 0.4 0.4 0.4 0.12 Pb (Lead) 1 5 1 1 0.5 0.3 As(Arsenic) 1 15 3 3 1.5 0.45 Hg (Mercury) 1 3 0.6 0.6 0.4 0.1 Co (Cobalt)2A 5 1 1 1 0.3 V (Vanadium) 2A 10 2 2 2 0.6 Ni (Nickel) 2A 20 4 4 4 1.2Tl (Thallium) 2B 8 1.6 1.6 1.6 0.5 Au (Gold) 2B 100 20 20 20 6 Pd(Palladium) 2B 10 2 2 2 0.6 Ir (Iridium) 2B 10 2 2 2 0.6 Os (Osmium) 2B10 2 2 2 0.6 Rh (Rhodium) 2B 10 2 2 2 0.6 Ru (Ruthenium) 2B 10 2 2 2 0.6Ag (Silver) 2B 10 2 2 2 0.6 Pt (Platinum) 2B 10 2 2 2 0.6 Li (Lithium) 3250 50 50 50 15 Sb (Antimony) 3 90 18 18 18 5.4 Ba (Barium) 3 700 140140 140 42 Mo (Molybdenum) 3 1,500 300 300 300 90 Sn (Tin) 3 600 120 120120 36 Cr (Chromium) 3 1,100 220 1.0 1.0 0.3 Al (Aluminum) other 6 6 66.0 1.88 B (Boron) other 3,400 680 50 50 15 Ca (Calcium) other 82,50016,500 50 50 15 Fe (Iron) other 1,300 260 10 10 3 K (Potassium) other470,000 94,000 94,000 94,000 28,200 Mg (Magnesium) other 35,000 7,000 5050 15 Na (Sodium) other 120,000 24,000 24,000 24,000 7,200 W (Tungsten)other N/A N/A N/A 1 1 Si (Silicon) In-house 19,200 3,840 100 100 30

In various embodiments, the trace elements injectable compositions ofthis application do not contain any detectable chromium or any chromiumat all. However, in other embodiments, for example, in a selenious acidinjection or zinc sulfate injection or even in an injectable compositioncontaining zinc, copper, selenium and manganese, the chromium contentwill not exceed about 0.3 μg/mL.

In various embodiments, the injectable compositions of this applicationalso include (i) iodine from about 0.0001 to about 0.2 mcg/kg/day,fluoride from about 0.0001 to about 2.7 mcg/kg/day, aluminum from about0.0001 to about 0.6 mcg/kg/day or a mixture thereof; or (ii) iodine fromabout 0 to about 0.2 mcg/kg/day, fluoride from about 0 to about 2.7mcg/kg/day, aluminum from about 0 to about 0.6 mcg/kg/day or a mixturethereof. In other embodiments, the injectable composition of thisapplication also includes (i) iron from about 0.0001 to about 10 μg/mL,silicon from about 0.0001 to about 100 μg/mL, magnesium from about0.0001 to about 50 μg/mL, calcium from about 0.0001 to about 50 μg/mL,boron from about 0.0001 to about 50 μg/mL or a mixture thereof; or (ii)iron from about 0 to about 10 μg/mL, silicon from about 0 to about 100μg/mL, magnesium from about 0 to about 50 μg/mL, calcium from about 0 toabout 50 μg/mL, boron from about 0 to about 50 μg/mL or a mixturethereof.

pH Considerations

In various aspects, the injectable composition described in thisapplication has a pH of from about 1.0 to about 5. In other aspects, theinjectable composition has a pH from about 1.5 to about 3.5 or fromabout 1.5 to about 4.0. In many aspects, the pH of the trace elementscomposition described in this application can vary from about 1.0, 1.1,1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5,2.6, 2.7, 2.8, 2.9, 3.0, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9,4.0, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 5.0. In someinstances, sodium hydroxide or sulfuric acid can be added to adjust thepH.

In some embodiments, pH limits for multi-element and/or single entitytrace elements injections are listed in Table 5 below.

TABLE 5 pH Limits for Multi-Element and Single Entity Trace ElementsInjections In- Fill USP process Drug Product size Container pH limit pHlimit Trace elements injectable  1 mL  2 mL vial 1.5 to 3.5 1.9 to 2.1composition, USP (3 mg/mL Zn as zinc sulfate, 0.3 mg/mL Cu as cupricsulfate, 55 μg/mL Mn as manganese sulfate, 60 μg/mL Se as seleniousacid) Zinc Sulfate Injection, 10 mL 10 mL vial 2.0 to 4.0 2.2 to 2.5 USP3 mg/mL (3 mg/mL Zn as zinc sulfate) Zinc Sulfate Injection,  5 mL  5 mLvial USP 5 mg/mL (5 mg/mL Zn as zinc sulfate) Selenious Acid Injection,10 mL 10 mL vial 1.8 to 2.4 2.0 to 2.2 USP

With the exception of selenious acid, the active ingredients in traceelements injectable compositions of this application, are formed fromtheir specific trace elements (zinc, copper, and manganese) by reactionwith acids (sulfuric acid or hydrochloric acid) to form their respectivemineral salt (e.g., zinc sulfate, cupric sulfate, and manganesesulfate). As weak acids, these salts are more stable in acidic solutionsbecause in neutral and alkaline solutions they form metal hydroxides(e.g., Zn(OH)₂; Cu(OH)₂; and Mn(OH)₂) which may precipitate. In the caseof selenious acid, to maintain the active ingredient in the ionizedform, a low pH is recommended.

The compositions of this application can be at least one of apreservative-free composition, a sterile composition, or a ready-to-useinjectable aqueous composition designed to be injected or added to aparenteral nutrition. However, in some embodiments, the compositions cancomprise a preservative. The preservative can be, in some cases, benzylalcohol in an amount of 0.9% by weight based on a total weight of theinjectable composition.

The injectable composition of trace elements can be dispensed in singledose vial or can be dispensed in multi-dose vials. The trace elementscomposition of this application is often presented as a 1-mL fill in a2-mL single dose preservative free vial. In many instances the vial canaccommodate from about be 1 mL, 2, 3, 4, 5, 6, 7, 8, 9 to about 10 mL offluid. In some cases, the vials can be prepared of Pyrex glass or havethe inside surface sprayed or coated with silica or can be made ofplastic material. This is to minimize the amount of aluminum that maypotentially be leaching from a glass vial to an amount not to exceed 0.6μg/kg of body weight of a patient in need of trace elements treatment orno more than 25 μg/L of intravenous (IV) infusion. In some cases, theamount of aluminum can vary from about 1 μg/mL (1 ppm) to about 6 μg/mLof aluminum. In other cases, there is no aluminum present.

In some embodiments, the injectable compositions comprising water, fromabout 900 μg to about 4,000 μg of zinc, from about 40 μg to about 400 μgof copper, from about 4 μg to about 90 μg of selenium, and from about 1μg to about 80 μg of manganese per 1 mL of the injectable compositionand can be used as a component of or additive to a parenteral nutritioncomprising at least one of an amino acid, a dextrose, a lipid, anelectrolyte or a mixture thereof. In other embodiments, the injectablecompositions comprise water, from about 2000 μg to about 4,000 μg ofzinc, from about 200 μg to about 400 μg of copper, from about 30 μg toabout 90 μg of selenium, and from about 20 μg to about 80 μg ofmanganese per 1 mL of the injectable composition and can be used as acomponent of or additive to a parenteral nutrition comprising at leastone of an amino acid, a dextrose, a lipid, an electrolyte or a mixturethereof.

The parenteral nutrition (PN) can include at least one of an amino acid,dextrose, a lipid, an electrolyte, or a mixture thereof. The at leastone of (i) the amino acid comprises lysine hydrochloride, phenylalanine,leucine, valine, threonine, methionine, isoleucine, tryptophan, alanine,arginine, glycine, proline, histidine, glutamic acid, serine, asparticacid, tyrosine or a mixture thereof; (ii) the dextrose comprisesdextrose monohydrate; (iii) the lipid comprises soybean oil,phospholipid, glycerin or a mixture thereof; or (iv) the electrolytecomprises sodium acetate trihydrate, potassium chloride, sodiumchloride, potassium acetate, sodium glycerophosphate anhydrous,magnesium sulfate heptahydrate, calcium chloride dihydrate, calciumgluconate or a mixture thereof. The resulting parenteral nutrition (PN)compositions can have a pH in a range from about 3.5 to about 7.9.

The injectable PN compositions described in this disclosure are alsononpyrogenic solutions. Unexpectedly, it has been found that includingtrace elements in a parenteral nutrition allowed the parenteralnutrition to be stable when stored from about 2° C. to about 8° C. forat least up to about 14 days. In some instances, when stored from about2° C. to about 8° C. for about 14 days, the parenteral nutrition canmaintain a pH from about 5.50 to about 5.90. Moreover, in otherinstances, when stored from about 2° C. to about 8° C. for about 14days, the parenteral nutrition comprises at least one of (i) no morethan 12 particle per mL that are greater than 10 μm; or (ii) no morethan 2 particle per mL that are greater than 25 μm.

In some embodiments, the parenteral nutrition can be in solution formand contains 0.2 mL to 1 mL trace elements injection per liter, can haveno or negligible amounts of aluminum, for example, from about 0.2 μg/mLto about 6 μg/mL, which is an amount that should not be exceeded. Inother cases, there is no aluminum present, which is therefore absent.

In many embodiments, when stored from about 2° C. to about 8° C. forabout 14 days, the parenteral nutrition does not exhibit microbialgrowth. Microbes that could otherwise grow in the parenteral nutritioncomposition include S. aureus, P. aeruginosa, E. coli, C. albicans, A.brasiliensis or a mixture thereof. As with other compositions describedin this application, parenteral nutrition compositions including traceelements are dispensed in a container typically is from about a 50 mLcontainer to about a 4000 mL container. The parenteral nutrition can bein glass, polyvinyl chloride, di(2-ethylhexyl) phthalate, polyethylene,polypropylene, polyvinyl chloride, polycarbonate, polyolefin or acombination thereof that can hold larger volume parenteral nutritionfrom about a 50 mL container to about a 4000 mL. The parenteralnutrition container can have at least one port for the injection of thetrace elements and/or other additives into the parenteral nutritioncontainer.

The trace elements, before being added to the parenteral nutrition, canbe in a single use vial or an ampule or in a container which comprises avial having a stopper acceptable for a parenteral drug product and/or acap. In many aspects, the trace elements can be placed into a 1 mLsingle dose vial or in 10 mL multiple dose vial. The vial or ampules canbe made of molded glass, glass coated with silica or polypropylene.

Parenteral Nutrition Compositions Containing Trace Elements

Parenteral nutrition refers to solutions for the intravenousadministration of nutrients necessary for the maintenance of life.Parenteral nutrition can be prepared not only for adult patients butalso for pediatric and/or neonatal patients.

An injectable parenteral nutrition containing trace elements is providedthat is stable for a longer period of time, thereby reducing the timeand costs associated with frequent admixing. The quality of life of thepatient and the caregiver is also improved by avoiding frequent trips tohealthcare facilities for the admixing of injectable parenteralnutrition. An injectable parenteral nutrition containing trace elementsis also provided that can be made in daily doses or in batches becauseit is stable for a longer period of time.

For example, because the PN containing one or more trace elements of thecurrent application has been found to be stable under refrigeration forup to 14 days, now the healthcare provider (e.g., pharmacist) can makethe daily dose of parenteral nutrition in batches for one or morepatients and, for example, a week supply or more can be admixed anddispensed for that particular patient, which eliminates the need andreduces costs as now that pharmacist will not need to be available on adaily basis to make the parenteral nutrition close in time to when it isadministered to the patient. Further, less frequent trips back and forthto the healthcare facility are required.

One or more trace elements can be added to the amino acids, dextrose,lipids, and/or electrolytes in the parenteral nutrition. The aminoacids, dextrose, lipids, and/or electrolytes in the parenteral nutritioncan be from commercially available parenteral nutrition products, suchas for example, AminoProtect® (essential and non-essential amino acids,Anazao Health Corp.), Aminosyn® II (amino acid injection withelectrolytes in dextrose injection with calcium, Hospira, Inc.),Aminosyn® II/Electrolytes (amino acid injection with electrolytes indextrose injection with calcium, Hospira Inc.), Aminosyn® M (acrystalline amino acid solution with electrolytes, Hospira Inc.),Aminosyn® (a crystalline amino acid solution with electrolytes, HospiraInc.), Aminosyn®-HBC (sulfite-free, amino acid injection high branchedchain, Hospira Inc.), Aminosyn®-PF (sulfite-free, amino acid injectionpediatric formula, Hospira Inc.), Aminosyn®-RF (sulfite free amino acidinjection 5.2% renal formula, Hospira Inc.), Aminosyn®/Electrolytes(these are essential and non-essential amino acid injection withelectrolytes, Hospira Inc.), BranchAmin® (branched chain amino acidsolution of essential amino acids isoleucine, leucine, and valine,Baxter Healthcare Corp.), Clinimix® E/Dextrose (amino acid/dextrose2.75/10, Baxter Healthcare Corp.), Clinimix® E/Dextrose (aminoacid/dextrose 2.75/5, Baxter Healthcare Corp.), Clinimix® E/Dextrose(amino acid/dextrose 4.25/10, Baxter Healthcare Corp.), Clinimix®E/Dextrose (amino acid/dextrose 4.25/25, Baxter Healthcare Corp.),Clinimix® E/Dextrose (amino acid/dextrose 4.25/5, Baxter HealthcareCorp.), Clinimix® E/Dextrose (amino acid/dextrose 5/15, BaxterHealthcare Corp.), Clinimix® E/Dextrose (amino acid/dextrose 5/20,Baxter Healthcare Corp.), Clinimix® E/Dextrose (amino acid/dextrose5/25, Baxter Healthcare Corp.), Clinimix® N14G30E (amino acid solutionwith electrolytes and a glucose solution with calcium, Baxter HealthcareCorp.), Clinimix® N9G15E (amino acid solution with electrolytes and aglucose solution with calcium chloride, Baxter Healthcare Corp.),Clinimix® N9G20E (amino acid solution 2.75% with electrolytes indextrose 10% solution for injection, Baxter Healthcare Corp.),Clinimix®/Dextrose (amino acid/dextrose 2.75/5, Baxter HealthcareCorp.), Clinimix®/Dextrose (amino acid/dextrose 4.25/10, BaxterHealthcare Corp.), Clinimix®/Dextrose (amino acid/dextrose 4.25/20,Baxter Healthcare Corp.), Clinimix®/Dextrose (amino acid/dextrose4.25/25, Baxter Healthcare Corp.), Clinimix®/Dextrose (aminoacid/dextrose 4.25/5, Baxter Healthcare Corp.), Clinimix®/Dextrose(amino acid/dextrose 5/15, Baxter Healthcare Corp.), Clinimix®/Dextrose(amino acid/dextrose 5/20, Baxter Healthcare Corp.), Clinimix®/Dextrose(amino acid/dextrose 5/25, Baxter Healthcare Corp.), Clinisol® SF(sulfite-free amino acid injection, Baxter Healthcare Corp.),Clinolipid® (lipid injectable emulsion, Baxter Healthcare Corp.),De′Flex® (peritoneal dialysis solutions (standard and low magnesium/lowcalcium) of dextrose and electrolytes in water for injection, FreseniusMedical Care North America), Elcys® (cysteine hydrochloride injection,Excela Pharma Science, LLC), FreAmine® HBC (amino acid injection, B.Braun Medical Inc.), FreAmine® III (amino acid injection, B. BraunMedical Inc.), Hyperlyte® CR (multi-electrolyte concentrate, B. BraunMedical Inc.), Hepatamine® (amino acid injection, B. Braun MedicalInc.), Intralipid® (purified soybean oil, purified egg lipids andglycerol anhydrous, Baxter healthcare Corp.), Isolyte® M in dextrose(multi-electrolyte injection in 5% dextrose, B. Braun Medical Inc.),Isolyte® P in dextrose (multi-electrolyte injection in 5% dextrose, B.Braun Medical Inc.), Isolyte® S in dextrose (multi-electrolyteinjection, B. Braun Medical Inc.), Kabiven® (amino acids, electrolytes,dextrose and lipid injectable emulsion, Fresenius Kabi), Liposyn® II(intravenous fat emulsion contains 5% safflower oil, 5% soybean oil, upto 1.2% egg phosphatides, Hospira, Inc.), NephrAmine® (essential aminoacid injection, B. Braun Medical Inc.), Novamine® (15% amino acidsinjection of essential and nonessential amino acids, Hospira Inc.),Nouress® (cysteine hydrochloride injection, Avadel LegacyPharmaceuticals, LLC), Nutrilipid® (plant based fat emulsion, B. BraunMedical Inc.), Nutrilyte® Pro (multi-electrolyte injection, AmericanRegent Inc.), Nutrilyte® II (multi-electrolyte injection, AmericanRegent Inc.), Omegaven® (fish oil triglycerides, Fresenius Kabi),Perikabiven® (amino acids, electrolytes, dextrose and lipid injectableemulsion, Fresenius Kabi USA, LLC), Plasma-Lyte® 56 (multipleelectrolytes and dextrose injection, Type 1, USP Baxter HealthcareCorporation) Plasma-Lyte 148 ® (multiple electrolytes and dextroseinjection, Type 1, USP Baxter Healthcare Corporation), Procalamine® (3%amino acid and 3% glycerin injection with electrolytes, B. Braun MedicalInc.), Plenamine® (15% amino acid injection, B. Braun Medical Inc.),Premasol® (sulfite-free amino acid injection, Baxter Healthcare Corp.),Prosol® (amino acids injection, Baxter Healthcare Corp.), Renamin®(amino acid Injection, Baxter Healthcare Corp.), Ringer's injection,SMOFlipid (fish oil and plant based fat emulsion, Fresenius Kabi),Synthamin® 17 (10% amino acid infusion product, Baxter HealthcareCorp.), Travasol® (amino acid injection for intravenous use, BaxterHealthcare Corp.), TrophAmine® (amino acid injection, B. Braun MedicalInc.), dextrose, sodium chloride, calcium chloride, potassium chloride,magnesium chloride, sodium acetate, or a combination thereof.

Dosing recommendations for pediatric patients is based on body weightand ranges from about 0.2 mL to about 0.8 mL per day as shown in Table 3above, where MDD refers to maximum daily dose.

Parenteral nutrition has become an integral part of the support of theneonate who is either unable to receive or tolerate enteral feeding.Feeding practices are generally based on birth weight, with the smallestinfants receiving parenteral nutrition for the longest time after birth.Generally, neonates include infants in the first four weeks after birth.Term neonates have an estimated weight of from about 3 kg to less than 5kg and preterm neonates have an estimated weight of less than 3 kg.Neonates also include very low birth weight (those having a weight ofless than 1500 g) and extremely low birth weight (those having a weightof less than 1000 g). These neonate infants are susceptible to growthfailure in postnatal life if nutritional demands are not met. Poorpostnatal growth in preterm infants is associated with adverseneurodevelopmental outcomes during childhood. Thus, early parentalnutrition is of paramount importance to provide appropriate protein andenergy in neonates, both preterm and term, when enteral nutrition is notfeasible or is suboptimal. We have, therefore, prepared a stableparenteral nutrition that can be used in a wide spectrum of patients,adult, pediatric and neonate.

The nutrient components of PN include dextrose, amino acids, fat,electrolytes, multivitamins, trace elements and water. Regarding thecontent and amounts of multivitamins and trace elements in PN solutionsor compositions compliance with recommendations by the American Societyfor Parenteral and Enteral Nutrition (A.S.P.E.N.) is followed. Inaccordance with A.S.P.E.N. recommendations, an injectable composition isprovided which is a parenteral nutrition. The parenteral nutrition orparenteral nutrition composition of this application comprises at leastone of an amino acid, a dextrose, a lipid, an electrolyte or a mixturethereof and a trace element component which comprises, consistsessentially of or consists of at least one of zinc, copper, selenium,and manganese. This means that, in some cases, the parenteral nutritioncontains only one of the trace elements, for example only zinc or copperor manganese or selenium. In other cases, the parenteral nutrition caninclude more than one trace element, for example, only zinc and copperor a mixture of all four of these elements.

In various embodiments, before any trace elements compositions are addedto the parenteral nutrition, the parenteral nutrition can comprise traceamounts of zinc, copper, manganese, and chromium from other sources, forexample water for injection and/or the container of the injectablecomposition. For example, in some cases, the parenteral nutrition cancomprise inherently and/or as impurities zinc in an amount of less thanabout 750 μg/L, copper in an amount of less than 75 μg/L, selenium in anamount of less than 15 μg/L, manganese in an amount of less than 13.7μg/L and chromium in an amount of less than 0.25 μg/mL.

In various aspects, the parenteral nutrition comprises, consistsessentially of or consists of from about 900 μg to about 4,000 μg ofzinc, from about 40 μg to about 400 μg of copper, from about 4 μg toabout 90 μg of selenium, and from about 1 μg to about 80 μg of manganeseper about 250 mL to 4000 mL of parenteral nutrition. In someembodiments, the parenteral nutrition comprises, consists essentiallyof, or consists of 3,000 μg of zinc, 300 μg of copper, 60 μg ofselenium, and 55 μg of manganese per about 250 mL to 4000 mL ofparenteral nutrition. In other embodiments, the parenteral nutritioncomprises, consists essentially of, or consists of 1,000 μg of zinc, 60μg of copper, 6 μg of selenium, and 3 μg of manganese per about 250 mLto 4000 mL of parenteral nutrition.

The elemental zinc can be provided by zinc sulfate or zinc heptahydrate.Copper can be provided by cupric sulfate or cupric sulfate pentahydrate.Manganese can be sourced from manganese sulfate or manganese sulfatemonohydrate. Selenium can be provided by selenious acid. Thus, in manycases, in the parenteral nutrition, zinc comprises zinc sulfate or zincsulfate heptahydrate in an amount of from about 13.1 mg to about 13.3mg, copper comprises, consists essentially of or consists of cupricsulfate or cupric sulfate pentahydrate in an amount of from about 1.1 mgto about 1.2 mg, manganese comprises manganese sulfate or manganesesulfate monohydrate in an amount of from about 0.16 mg to about 0.18 mgand selenium comprises selenious acid in an amount of from about 95 μgto about 99 μg per about 250 mL to 4000 mL of parenteral nutrition.

In some embodiments, in the parenteral nutrition, the zinc sulfate orzinc sulfate heptahydrate comprises, consists essentially of, orconsists of an amount of about 13.2 mg, the cupric sulfate or the cupricsulfate pentahydrate comprises, consists essentially of or consists ofan amount of about 1.179 mg, the manganese sulfate or manganese sulfatemonohydrate comprises, consists essentially of or consists of an amountof about 0.0169 mg and the selenious acid comprises, consistsessentially of or consists of an amount of about 98 μg.

In some embodiments, each trace element can be added to a PN solution,one at a time and the injection composition of this application cancontain only one of these trace elements, for example, only zinc,copper, manganese, or selenium. This approach allows for tailoring of aPN solution to the needs of a specific patient in need who might have azinc deficiency only, for example, but is not deficient in copper,manganese, or selenium.

In some embodiments, a selenious acid injection, USP can be indicatedfor use as a supplement to intravenous solutions given for parenteralnutrition (PN). Administration of selenium in PN solutions helps tomaintain plasma selenium levels and to prevent depletion of endogenousstores and subsequent deficiency symptoms. Each mL contains 98.0 μg ofselenious acid, USP (equivalent to 60 μg of elemental selenium), nitricacid, national formulary (NF) for pH adjustment (1.8 to 2.4) and waterfor injection, USP quantity sufficient (q.$). In some embodiments, thetrace element composition comprises selenium or selenious acid and has apH of about 3.5 to about 7.9.

In many aspects, selenium is present in the same concentration of 60 μgof elemental selenium per mL in the injectable composition comprisingbeside selenium, the multi-trace product which contains zinc sulfateheptahydrate 13.20 mg (equivalent to 3 mg zinc), cupric sulfatepentahydrate 1.18 mg (equivalent to 0.3 mg copper), and manganesesulfate monohydrate 169 μg (equivalent to 55 μg manganese) sulfuric acidfor pH adjustment and water for injection q.s. Since selenious acidinjection, USP could be administered in parenteral solutions as both,single and a component of multi-trace solutions, it was deemedappropriate to utilize the study of the trace elements injection whichalso contains zinc, copper and manganese USP for selenious acidinjection, USP.

In many aspects, the parenteral nutrition includes at least one of (i)the amino acid which comprises lysine hydrochloride, phenylalanine,leucine, valine, threonine, methionine, isoleucine, tryptophan, alanine,arginine, glycine, proline, histidine, glutamic acid, serine, asparticacid, tyrosine or a mixture thereof; (ii) the dextrose which comprisesdextrose monohydrate; (iii) the lipid which comprises soybean oil,phospholipid, glycerin or a mixture thereof; (iv) the electrolyte whichcomprises sodium acetate trihydrate, potassium chloride, sodiumchloride, potassium acetate, sodium glycerophosphate anhydrous,magnesium sulfate heptahydrate, calcium chloride dihydrate, calciumgluconate or a mixture thereof and (v) water, generally water forinjection. In various aspects, the parenteral nutrition solution isnonpyrogenic.

In various aspects, the parenteral nutrition has a pH that varies isfrom about 3.5 to about 7.9. In some cases, the pH can be from about3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8,4.9, 5.0, 5.1, 5.2, 5.3, 5.3, 5.5, 5.7, 5.8, 5.9, 6.0, 6.1, 6.2, 6.3,6.4, 6.5, 6.7, 6.8, 6.9, 7.0, 7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 7.8 toabout 7.9.

It has been surprisingly found that when stored from about 2° C. toabout 8° C. for up to about 14 days, the parenteral nutrition whichincludes the trace element composition of this application is stableremaining in a state or condition that is suitable for administration toa patient and without undergoing a substantial change in the potency ofthe active agent in the formulation over this specified time period.

Further, when stored from about 2° C. to about 8° C. for about 14 daysthe parenteral nutrition maintained a pH from about 5.50 to about 5.90.When stored from about 2° C. to about 8° C. for about 14 days, theparenteral composition of this application comprises, consistsessentially of or consists of at least one of (i) no more than 12particle per mL that are greater than 10 μm; or (ii) no more than 2particle per mL that are greater than 25 μm. Moreover, when theparenteral nutrition of this disclosure is stored from about 2° C. toabout 8° C. for about 14 days, it was surprisingly found that it did notexhibit any significant microbial growth with respect to such microbesas S. aureus, P. aeruginosa, E. coli, C. albicans, A. brasiliensis or amixture thereof.

Generally parenteral nutrition can be prepared in a dual or triplechamber infusion bag which can have a separate port for the addition oftrace elements prior to administration. Aluminium (Al) toxicity inparenteral nutrition solutions (PNS) has been a problem for manypatients with impaired kidney function who frequently are in need ofparenteral nutrition. In accordance with 21CFR201.323 (revised as ofApr. 1, 2019), regarding aluminum content, the Federal DrugAdministration prescribes that the parenteral nutrition solution mustcontain a warning that the solution contains no more than 25 mcg/L ofaluminum which may reach toxic levels with prolonged administration inpatients with renal impairment. Preterm infants are at greater riskbecause their kidneys are immature, and they require large amounts ofcalcium and phosphate solutions which contain aluminum. Patients withrenal impairment, including preterm infants, who receive parenterallevels of aluminum at greater than 4 to 5 mcg/kg/day, accumulatealuminum at levels associated with central nervous system and bonetoxicity. Tissue loading may occur at even lower rates ofadministration. Nevertheless, whether or not the parenteral nutrition ofthis disclosure includes the trace elements composition as a component,the amount of aluminum should be kept in a daily exposure amount fromabout 0.1 μg/kg, 0.2, 0.3, 0.4, 0.5 to about 0.6 μg/kg, in any event notto exceed 0.6 μg/kg. In many cases, the parenteral nutrition of thisapplication does not contain any aluminum and/or chromium as impurities.

In some embodiments, parenteral nutrition includes multivitamins, suchas for example, vitamins, A, D, E, C, B1, B2, B6, B12, niacinamide,dexpanthenol, biotin and/or folic acid. In other embodiments, the traceelements when added to the PN may interact with the vitamins in the PNand may cause precipitation. Thus, in some embodiments, the injectablecomposition containing trace elements is added to parenteral nutritionthat does not contain any vitamins.

In some embodiments, to the parenteral nutrition comprising at least oneof an amino acid, a dextrose, a lipid, an electrolyte or a mixturethereof and a trace element, one or more injectable vitamins can beadded. These one or more injectable vitamins can be added individuallyor together to the parenteral nutrition. These vitamins include one ormore of vitamin A (e.g., retinol), vitamin D (e.g., ergocalciferol),vitamin E (e.g., dl-alpha-tocopheryl acetate), vitamin K (e.g.,phytonadione), vitamin C (e.g., ascorbic acid), niacinamide, vitamin B2(e.g., as riboflavin 5-phosphate sodium), vitamin B1 (e.g., thiamine),vitamin B6 (e.g., pyridoxine HCl), dexpanthenol (e.g., d-pantothenylalcohol), biotin, folic acid, B12 (e.g., cyanocobalamin), or acombination thereof.

An example of vitamins for injection for adults (INFUVITE® Adult) thatcan be added to the parenteral nutrition before or after the addition ofthe trace elements include those vitamins in a two vial system listedbelow.

Ingredient Amount per Unit Dose Vial 1* Fat Soluble Vitamins** Vitamin A(retinol) 1 mg^(a) Vitamin D (ergocalciferol) 5 mcg^(b) Vitamin E(dl-alpha-tocopheryl acetate) 10 mg^(c) Vitamin K (phytonadione) 150 mcgWater Soluble Vitamins Vitamin C (ascorbic acid) 200 mg Niacinamide 40mg Vitamin B2 (as riboflavin 5-phosphate sodium) 3.6 mg Vitamin B1(thiamine) 6 mg Vitamin B6 (pyridoxine HCl) 6 mg Dexpanthenol(d-pantothenyl alcohol) 15 mg *With 30% propylene glycol and 2% gentisicacid ethanolamide as stabilizers and preservatives; sodium hydroxide forpH adjustment; 1.6% polysorbate 80; 0.028% polysorbate 20; 0.002%butylated hydroxytoluene; 0.0005% butylated hydroxyanisole. **Fatsoluble vitamins A, D, E and K are water solubilized with poly- sorbate80. ^(a)1 mg vitamin A equals 3,300 USP units. ^(b)5 mcg ergocalciferolequals 200 USP units. ^(c)10 mg vitamin E equals 10 USP units. Vial 2*Biotin 60 mcg Folic acid 600 mcg B12 (cyanocobalamin) 5 mcg *With 30%propylene glycol; and citric acid, sodium citrate, and sodium hydroxidefor pH adjustment.

An example of pediatric injectable vitamins that can be added to theparenteral nutrition before or after the addition of the trace elementsinclude those found in INFUVITE® PEDIATRIC

Each 4 mL of Vial 1 contains 10 vitamins (shown below).

Active Ingredients in 4 mL of Vial 1

Active Ingredient Quantity Ascorbic acid (Vitamin C) 80 mg Vitamin A*(as palmitate) 2,300 IU (equals 0.7 mg) Vitamin D3* (cholecalciferol)400 IU (equals 10 mcg) Thiamine (Vitamin B1) (as the hydrochloride) 1.2mg Riboflavin (Vitamin B2) (as riboflavin 5- 1.4 mg phosphate sodium)Pyridoxine HCl (Vitamin B6) 1 mg Niacinamide 17 mg Dexpanthenol (asd-pantothenyl alcohol) 5 mg Vitamin E* (dl-α-tocopheryl acetate) 7 IU(equals 7 mg) Vitamin K1* 0.2 mg *Polysorbate 80 is used to watersolubilize the oil-soluble vitamins A, D, E, and K.Inactive ingredients in Vial 1: 50 mg polysorbate 80, sodium hydroxideand/or hydrochloric acid for pH adjustment, and water for injection.Each 1 mL of Vial 2 contains 3 vitamins (see shown below).

Active Ingredients in 1 mL of Vial 2

Active Ingredient Quantity Folic acid 140 mcg Biotin  20 mcg Vitamin B12(cyanocobalamin)  1 mcgInactive ingredients in Vial 2: 75 mg mannitol, citric acid and/orsodium citrate for pH adjustment and water for injection.Container of the Trace Elements Injectable Composition

In various embodiments, the injectable composition containing traceelements is disposed in a container. The container can have a variety ofvolumes. Typically, the container for the trace elements injectablecomposition before it is added to a parenteral solution can have avolume of from about 1 mL to about 10 mL. In some examples, thecontainer can have a volume of from about 1 mL, 2, 3, 4, 5, 6, 7, 8, 9to about 10 mL.

Containers in which the trace elements composition can be stored includeany container that is suitable for storing a pharmaceutical. Typicalcontainers can be inert to the trace elements composition. In someembodiments, treated glass containers such as siliconized glasscontainers are also useful. In some embodiments, plastic containers canalso be used that are inert and/or are treated or coated to be inert.Suitable containers include vials, ampules, bottles, cartridges,syringes, pre-filled syringes, plastic IV bags, or the like. Thecontainer can be sealed with a closure, such as, for example, a rubberstopper, plunger, lid, top or the like. Suitable inert or non-reactivestoppers may be obtained from several commercial manufacturers. Ingeneral, the closures can be made with inert, non-reactive materialswith little to no leachables. In some embodiments, closures also includethose that are coated or treated with inert materials such assiliconized polymer or Teflon/fluoropolymer coated/treated closures. Byway of example and not in limitation of the present application, rubberclosures that are suitable in the present application include bromobutylrubber, chlorobutyl rubber, fluoropolymers, silicones, siliconizedbromobutyl rubber, and/or siliconized chlorobutyl rubber.

Non-reactive, non-elastomeric closures are also useful for the traceelements composition. For example, non-rubber closures include metalclosures, or plastics such as polyethylene, polypropylene, nylon,polyurethane, polyvinylchloride, polyacrylates, polycarbonates, or thelike that cause little to no degradation to the trace elementscomposition or that are treated or coated so as to cause little or nodegradation of the trace elements composition.

In many aspects, useful containers for the injectable compositions ofthis disclosure include a single use vial or ampule or the containerscomprise a vial having a barrier coated stopper and/or an aluminum cap.In some embodiments, the vial or ampule comprises molded glass orpolypropylene. In other cases, the container for the injectablecompositions of this disclosure can be made of a variety of materials.Non-limiting materials can include glass, a plastic (e.g., polyethylene,polypropylene, polyvinyl chloride, polycarbonate, etc.), the like, or acombination thereof provided that it can both prevent oxygen penetrationand minimize aluminum, heavy metals and anions contamination to thecomposition. In certain embodiments, the container is fabricated frommultilayered plastic (PL 2501, PL 2040), also known as a galaxycontainer, a plastic container primarily for intravenous use. Solutionsare in contact with the polyethylene layer of the container and canleach out certain chemical components of the plastic in very smallamounts within the expiration period.

In other aspects, the container can be fabricated from glass as a singleuse 1 mL vial, for example, a Type I glass vial for injectable products.In some aspects, the pharmaceutical compositions of this disclosure canalso be stored in glass vials or ampules, for example, single use 1 mLglass vials or ampules. In various embodiments, the container can beType I glass (e.g., molded glass, tubing glass, glass coated withsilica, etc.), plastic (e.g., polymeric materials such as polypropylene,COC, COP, multi-shell, etc.) or the like. In some embodiments, Type Iglass can be a borosilicate glass, which is relatively inert with goodchemical resistance.

In some cases, the injectable composition is dispensed into a containerthat can be a single use container, for example, a single use vial orampule or the container comprises a vial having a barrier coated stopperand/or an aluminum cap. As described above, the vial or ampule can bemade of molded glass or polypropylene. The container may, optionally,further comprise a light barrier. In certain embodiments, the lightbarrier can be an aluminum material disposed over a pouch.

The injectable composition of trace elements can be dispensed, forexample, in 1 mL single dose vial or can be dispensed in 10 mLmulti-dose vials. In some cases, the vials can be prepared of Pyrexglass or sprayed or coated with silica or can be made of plasticmaterial. This is to minimize the amount of aluminum that maypotentially be leaching from a glass vial to a daily exposure amount notto exceed 0.6 μg/kg of body weight of a patient in need of traceelements treatment or no more than 25 μg/L of intravenous (IV) infusionfor parenteral nutrition. In some cases, the daily exposure amount ofaluminum can vary from about 0.1 μg/kg to about 0.6 μg/kg of aluminum.In other cases, there is no detectable aluminum present in theinjectable compositions of this application.

To ensure that the amount of aluminum in a multi-component PN ismaintained below 25 μg/L (CFR 201.323), choosing a low aluminum contentvial such as Gerresheimer Gx®33 is expected to reduce the amount ofaluminum leached from a glass container. The West 4432 FluroTec® B2-40coated stopper was selected because the barrier technology of theFluroTec® film, in combination with the B2-40 coating, utilized in theWest 4432 FluroTec® B2-40 stopper can significantly reduce potentialsources of particulate contamination, specifically by reducing inorganicand organic leachable substances and by providing lubricity without theneed for free silicone oil. Using glass vials with or without a coatedstopper provided a targeted shelf-life of 24 months.

The container in which the injectable compositions are held may affectthe level of certain components. In certain embodiments, the injectablecomposition can be enclosed in a single-use container. These containerscan include, for example, vials, ampules, or syringes. As previouslydiscussed, the pH range for the injectable composition of eitherparenteral nutrition and/or injectable composition comprising traceelements varies from about 1.0 to about 7. This pH may disrupt theplastic coating or silicon coating inside the glass container andaluminum, heavy metals and anions could leach during the shelf life ofthe product, especially over prolonged storage of the product.

Elemental impurities monitored in the finished drug products describedin this disclosure include without limitation Cd, Pb, As, Hg, Co, V, Ni,Tl, Au, Pd, Ir, Os, Rh, Ru, Se, Ag, Pt, Li, Sb, Ba, Mo, Cu, Sn, and Cr.In some embodiments, the injectable composition comprising trace elementor the parenteral nutrition comprising the injectable compositioninclude 0.0, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2,1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7,2.8, 2.9, 3, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1, 4.2,4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, to about 5.0 ppb of these impurities.However, the levels of specific metals ions are monitored in thefinished drug product units over the entire shelf life but are notquantified in the bulk Water for Injection (WFI), USP used to preparethe batch. Rather, the level of soluble metals and any otherelectrolytes is measured in the bulk WFI, USP via measurement ofconductivity.

In some embodiments, the one or more trace elements are indicated foruse as a supplement to intravenous solutions given for parenteralnutrition. Administration of the solution in parenteral TPN solutionshelps to maintain plasma levels of one or more elements: zinc, copper,manganese, selenium or optionally chromium and to prevent depletion ofendogenous stores of these trace elements and subsequent deficiencysymptoms. In some embodiments, the one or more trace elements can beused to maintain, supplement or increase one or more trace elements:zinc, copper, manganese, selenium or optionally chromium.

The trace element can be elemental and sourced from any salt, hydrate,and/or solvate forms thereof. For example, the elemental zinc can befrom, for example, zinc gluconate trihydrate, zinc gluconate, zincchloride, zinc sulfate, zinc sulfate heptahydrate, zinc oxide, zincsulfide, zinc trisodium, zinc carbonate, zinc acetate, zinc citrate,zinc lactate, zinc hydroxide or a combination thereof. For example, theelemental manganese can be from, for example, manganese sulfate,manganese sulfate monohydrate, manganese chloride, manganese gluconate,manganese glycerophosphate, manganese carbonate, manganese hydroxide, ora combination thereof. For example, the elemental copper can be from,for example, cupric sulfate, cupric sulfate pentahydrate, cuprichydroxide, cupric oxide, copper carbonate, copper citrate, coppergluconate, or a combination thereof. For example, the elemental seleniumcan be from, for example, selenious acid, sodium selenite, disodiumselenite, sodium hydrogen selenite, potassium selenite, zinc selenite,copper selenite, manganese selenite or a combination thereof. In someembodiments, the zinc selenite, copper selenite, or manganese seleniteor a combination thereof are not readily soluble in water but at a pH ofbetween about 1.5 to about 3.5, the zinc selenite, copper selenite, ormanganese selenite or a combination are water soluble. For example, theelemental chromium can be from, for example, chromium trichloride,chromium trichloride hexahydrate, chromium trisulfate or a combinationthereof.

The trace elements can be in the trace elements composition in thefollowing ratios:

Ratio elemental Zn to Ratio elemental Zn to Ratio elemental Zn toProduct elemental Cu elemental Mn elemental Se MTE-4 ® 1 mg Zn to 0.4 mg1 mg Zn to 0.1 mg Mn N/A Cu Ratio: 2.5 to 1 Ratio: 10 to 1) MTE-4 ® 5 mgZn to 1 mg 5 mg Zn to 0.5 mg Mn N/A Conc. Cu Ratio: 5 to 1 Ratio: 10 to1 MTE-4 ® 1.5 mg Zn to 0.1 mg 1.5 mg Zn to 0.025 mg N/A Neonatal CuRatio: 15 to 1 Mn Ratio: 60 to 1 MTE-4 ® 1 mg Zn to 0.1 mg 1 mg Zn to0.025 mg N/A Pediatric Cu Ratio: 10 to 1 Mn Ratio: 40 to 1 MTE-5 ® 1 mgZn to 0.4 mg 1 mg Zn to 0.1 mg Mn 1 mg Zn to 0.02 mg Cu Ratio: 2.5 to 1Ratio: 10 to 1 Se Ratio: 50 to 1 MTE-5 ® 5 mg Zn to 1 mg 5 mg Zn to 0.5mg Mn 5 mg Zn to 0.06 mg Conc. Cu Ratio: 5 to 1 Ratio: 10 to 1 Se Ratio:83.3 to 1

These ratios are elemental to elemental ratios (e.g., elemental Zn toelemental Cu, elemental Zn to elemental Mn, etc.). In some embodiments,these ratios can also be the ratios for the newer formulations that haveno or little chromium. In some embodiments, the trace elements are in aratio of: elemental zinc to elemental copper from about 100:1, 80:1,70:1, 60:1, 50:1, 30:1, 20:1, 15:1, 10:1, 5:1, 2.5:1 to about 2:1;elemental zinc to elemental manganese in a ratio from about 4000:1,3,000:1, 2,000:1, 1,000:1, 500:1, 200:1, 100:1, 60:1, 55:1, 50:1, 45:1,40:1, 35:1, 30:1, 25:1, 20:1, 15;1, 10:1 to about 5:1; elemental zinc toelemental selenium in a ratio from about 1000:1, 500:1, 200:1, 100:1,90:1, 85:1, 83.3:1, 80:1, 75:1, 70:1, 65:1, 60:1, 55:1, 50:1, 45:1,40:1, 35:1, 30:1, 25:1, 20:1, 15:1, 10:1 to about 9:1; elemental copperto elemental selenium in a ratio from about 100:1, 50:1, 20:1, 15:1,10:1, 5:1, 3:1, 2:1, 1:1 to about 0.4:1; elemental copper to elementalmanganese in a ratio from about 400:1, 300:1, 200:1, 100:1, 90:1, 85:1,80:1, 75:1, 70:1, 65:1, 60:1, 55:1, 50:1, 45:1, 40:1, 35:1, 30:1, 25:1,20:1, 15:1, 10:1, 5.5:1, 5:1, 2.5:1, 2:1, 1:1 to about 0.5:1; and/orelemental selenium to elemental manganese in a ratio from about 100:1,90:1, 75:1, 50:1, 30:1, 20:1, 10:1, 5:1, 3;1, 2:1, 1.1:1, 1:1, 0.5:1,0.4:1 to about 0.05:1.

In some embodiments, the trace elements can be in the trace elementscomposition in the following elemental ratios: Zn/Cu: 10:1, Zn/Se: 50:1,Zn/Mn: 55:1, Cu/Se: 5:1, Cu/Mn: 5.5:1, and/or Se/Mn: 1.1:1. In someembodiments, these can lead to the trace elements composition stabilityand the parenteral nutrition stability.

Exemplary trace elements compositions for use in the current applicationinclude Multitrace®-4, available from American Regent Shirley, NY, USA.

Multitrace ®-4 Multitrace ®-4 Multitrace ®-4 Multitrace ®-4Multitrace ®-4 Concentrate Concentrate Neonatal Pediatric (TraceElements (Trace Elements (Trace Elements (Trace Elements (Trace ElementsInjection 4, USP) Injection 4, USP) Injection 4, USP) Injection 4, USP)Injection 4, USP) 10 mL Multiple 1 mL Single 10 mL Multiple 2 mL SingleDose 3 mL Single Dose Dose Vial Dose Vial Dose Vial Vial Vial (Preservedwith (Preser- (Preserved with (Preser- (Preservative 0.9% Benzyl vative0.9% Benzyl vative Free) Alcohol) Free) Alcohol) Free) Content ContentContent Content Content of Trace of Trace of Trace of Trace of TraceTrace Elements/ Trace Elements/ Trace Elements/ Trace Elements/ TraceElements/ Elements 1 mL Elements 1 mL Elements 1 mL Elements 1 mLElements 1 mL Zinc (as 1 mg Zinc (as 5 mg Zinc (as 5 mg Zinc (as 1.5 mgZinc (as 1 mg Sulfate) Sulfate) Sulfate) Sulfate) Sulfate) Copper 0.4 mgCopper 1 mg Copper 1 mg Copper 0.1 mg Copper 0.1 mg (as (as (as (as (asSulfate) Sulfate) Sulfate) Sulfate) Sulfate) Manganese 0.1 mg Manganese0.5 mg Manganese 0.5 mg Manganese 25 mcg Manganese 25 mcg (as (as (as(as (as Sulfate) Sulfate) Sulfate) Sulfate) Sulfate) Chromium 4 mcgChromium 10 mcg Chromium 10 mcg Chromium 0.85 mcg Chromium 1 mcg (as (as(as (as (as Chloride Chloride Chloride Chloride Chloride In N/A In N/AIn N/A In N/A In N/A Water Water Water Water Water for for for for forInjection, Injection, Injection, Injection, Injection, USP USP USP USPUSP pH Solution pH Solution pH Solution pH Solution pH Solution may maymay may may be be be be be adjusted adjusted adjusted adjusted adjustedwith with with with with Sulfuric Sulfuric Sulfuric Sulfuric SulfuricAcid Acid Acid Acid Acid and/or and/or and/or and/or and/or SodiumSodium Sodium Sodium Sodium Hydroxide Hydroxide Hydroxide HydroxideHydroxide

Exemplary trace elements compositions for use in the current applicationcan also include Multitrace®-5, available from American Regent Shirley,NY, USA.

Multitrace ®-5 Multitrace ®-5 Concentrate (Trace Elements (TraceElements Multitrace ®-5 Concentrate Injection 5, USP) Injection 5, USP)(Trace Elements Injection 5, USP) 10 mL Multiple Dose Vial 1 mL SingleDose Vial 10 mL Multiple Dose Vial (Preserved with 0.9% (PreservativeFree) (Preserved with 0.9% Benzyl Benzyl Alcohol) Alcohol) Trace Contentof Trace Trace Content of Trace Trace Content of Trace ElementsElements/1 mL Elements Elements/1 mL Elements Elements/1 mL Zinc (as 1mg Zinc (as 5 mg Zinc (as 5 mg Sulfate) Sulfate) Sulfate) Copper (as 0.4mg Copper (as 1 mg Copper (as 1 mg Sulfate) Sulfate) Sulfate) Manganese0.1 mg Manganese 0.5 mg Manganese 0.5 mg (as (as (as Sulfate) Sulfate)Sulfate) Chromium 4 mcg Chromium 10 mcg Chromium 10 mcg (as (as (asChloride) Chloride) Chloride) Selenium 20 mcg Selenium 60 mcg Selenium60 mcg (as (as (as Selenious Selenious Selenious Acid) Acid) Acid) InWater N/A In Water N/A In Water N/A for for for Injection, Injection,Injection, USP USP USP pH Solution pH Solution pH Solution may be may bemay be adjusted with Sulfuric adjusted adjusted Acid with with SulfuricSulfuric Acid Acid and/or Sodium Hydroxide

Exemplary trace elements compositions that can be used in the currentapplication can include those without chromium some listed below.

Neonatal Pediatric Trace Elements Trace Elements Trace Elements TraceElements Trace Elements Injection 3, Injection 3, USP Injection 3, USPInjection 3, USP Injection 3, USP USP (No Chromium) (No Chromium) (NoChromium) (No Chromium) (No Chromium) 10 mL Multiple Dose Vial 1 mLSingle Dose Vial 10 mL Multiple Dose Vial 2 mL Single Dose Vial 3 mLSingle Dose Vial (Preserved with 0.9% (Preservative (Preserved with 0.9%(Preservative (Preservative Benzyl Alcohol) Free) Benzyl Alcohol) Free)Free) Content of Content of Content of Content of Content of Trace TraceTrace Trace Trace Trace Trace Trace Trace Trace Elements Elements/1 mLElements Elements/1 mL Elements Elements/1 mL Elements Elements/1 mLElements Elements/1 mL Zinc (as   1 mg Zinc (as   5 mg Zinc (as   5 mgZinc (as 1.5 mg Zinc (as 1 mg Sulfate) Sulfate) Sulfate) Sulfate)Sulfate) Copper (as 0.4 mg Copper (as   1 mg Copper (as   1 mg Copper(as 0.1 mg Copper (as 0.1 mg Sulfate) Sulfate) Sulfate) Sulfate)Sulfate) Manganese 0.1 mg Manganese 0.5 mg Manganese 0.5 mg Manganese 25mcg Manganese 25 mcg (as (as (as (as (as Sulfate) Sulfate) Sulfate)Sulfate) Sulfate) In Water for Injection, N/A In Water for Injection,N/A In Water for Injection, USP USP USP pH Solution pH Solution pHSolution pH Solution pH Solution may be may be may be may be may beadjusted adjusted adjusted adjusted adjusted with with with with withSulfuric Sulfuric Sulfuric Sulfuric Sulfuric Acid Acid Acid Acid Acidand/or and/or and/or and/or and/or Sodium Sodium Sodium Sodium SodiumHydroxide Hydroxide Hydroxide Hydroxide Hydroxide

Trace Elements Compositions having 4 trace elements with no chromium areshown below.

Trace Elements 4 Trace Elements 4 Trace Elements 4 Injection InjectionConcentrated Injection Concentrated (No Chromium) (No Chromium) (NoChromium) 10 mL Multiple Dose Vial 1 mL Single Dose Vial 10 mL MultipleDose Vial (Preserved with 0.9% (Preservative Free) (Preserved with 0.9%Benzyl Alcohol) Benzyl Alcohol) Trace Content of Trace Trace Content ofTrace Trace Content of Trace Elements Elements/1 mL Elements Elements/1mL Elements Elements/1 mL Zinc (as 1 mg Zinc (as 5 mg Zinc (as 5 mgSulfate) Sulfate) Sulfate) Copper (as 0.4 mg Copper (as 1 mg Copper (as1 mg Sulfate) Sulfate) Sulfate) Manganese 0.1 mg Manganese 0.5 mgManganese 0.5 mg (as Sulfate) (as Sulfate) (as Sulfate) Selenium 20 mcgSelenium 60 mcg Selenium 60 mcg (as (as (as Selenious SeleniousSelenious Acid) Acid) Acid) In Water N/A In Water N/A In Water N/A forfor for Injection, Injection, Injection, USP USP USP pH Solution pHSolution pH Solution may may be may be be adjusted adjusted adjustedwith Sulfuric with with Acid Sulfuric Sulfuric Acid Acid and/or SodiumHydroxideHeadspace Oxygen

In certain embodiments, the trace elements further comprise within thecontainer, headspace gas that includes oxygen in an amount of from about0.5% v/v to about 5.0% v/v, or from about 0.5% v/v to about 4.0% v/v, orfrom about 0.5% v/v to about 3.5% v/v, from about 0.5% v/v to about 3.0%v/v, or from about 0.5% v/v to about 2.5% v/v, or from about 0.5% v/v toabout 2.0% v/v, or from about 0.5% v/v to about 1.5% v/v, or from about0.5% v/v to about 1.0% v/v, or in some cases from about 0.1% v/v toabout 0.5% v/v, or from about 0.1% v/v to about 0.4% v/v, or from about0.1% v/v to about 0.3% v/v, or from about 0.1% v/v to about 0.2% v/v.For the sake of clarity and the ease of discussion and measurement,these values are taken for the injectable composition at the time of itsmanufacture (“time zero” data point), or during and up to 1 month fromtime zero. Additional time points beyond the 1 month from time zero datapoint may provide similar headspace oxygen levels.

Without wishing to be bound by a particular theory, the dissolved oxygenlevels, and the head space oxygen levels within a sealed container ofinjectable compositions described herein may reach an equilibrium atsome time point during its shelf-life. Such equilibrium may bemaintained for a very short time, i.e., for a few seconds, or for a verylong time, i.e., for several months. Such equilibrium may on occasion bedisturbed by simple agitation. Therefore, it should be recognized thatdissolved oxygen levels and headspace oxygen levels may fluctuate fromone time point to another in terms of absolute numbers. However, thenumbers are expected to stay within the ranges disclosed herein.Occasionally, one number (e.g., dissolved oxygen) may exceed or fall outof a certain range (e.g., from about 0.5 to about 3.0 PPM) at a 15 daytime point but may fall within that range at some other time point(e.g., 30 day time point, or later). Therefore, in some aspects, theranges, subranges, and specific data points disclosed and discussedherein are suitable for time points beyond the time zero- and 1-monthtime points. In one aspect, the time points could be extended to fromabout 2 months, 3 months, 6 months, 9 months, 12 months, 15 months, 18months, and about 24 months.

In some cases, the total amount of oxygen in the sealed container may bean appropriate measure to evaluate the stability of the injectablecompositions. For example, the total amount of oxygen within thecontainer may be arrived at by adding up the amount of dissolved oxygenin the carrier and the amount of head space oxygen. These values canalso be expressed independently in separate units (i.e., dissolvedoxygen as ppm and head space oxygen as % v/v). An example would be thatthe parenteral nutrition or the injectable composition of trace elementscontains a dissolved oxygen level of from about 0.0 ppm to 5.0 ppm, morespecifically, from about 0.0, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8,0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.2, 2.3,2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8,3.9, 4.0, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, to about 5.0 ppmand a head space oxygen level of about 0.5% v/v to about 4.0% v/v. Incertain embodiments, the total amount of oxygen within the container isexpected to increase upon filling into vials due to the inherentaeration of the drug product during filling (e.g., splashing). Based onwhat has been seen for other drug products, the dissolved oxygen in thefinished units (e.g., vials) is expected to be in the range of fromabout 0.0 ppm to about 7.0 ppm, more specifically, from about 0.0, 0.1,0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5,1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3,3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1, 4.2, 4.3, 4.4,4.5, 4.6, 4.7, 4.8, 4.9, 5.0, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8,5.9, 6, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9 to about 7.0 ppm.

The amount of oxygen present in the headspace of the container can becontrolled by filling the headspace with an inert gas, such as nitrogenor argon. Alternatively, the head space oxygen may be controlled byvacuum operation without using an inert gas. In another aspect, the headspace oxygen may be controlled by a combination of vacuum operation andinert gas overlay. In one other aspect, the head space oxygen iscontrolled by repeated pulses of vacuum and inert gas overlay in tandemsuch that the process may start first with vacuum operation followed byinert gas overlay followed by vacuum operation. The combination ofvacuum operation and inert gas overlay (or inert gas overlay and vacuumoperation) is considered one pulse when both steps are used together. Atypical head space control operation may comprise from one to eightpulses. Typically, there could be two, three, four, or five pulses. Eachpulse could last from about one tenth of one second to five seconds orfrom five to fifteen seconds when conducted by automated high-speedequipment custom designed for this specific purpose. In someembodiments, the pulse may last from about 0.1 to about 2.0 seconds. Insome embodiments, the pulse may last from about 0.1 to about 1.0seconds, or from about 0.1 to about 0.4 seconds. When done using manualmethods, each pulse could take up to 30-60 seconds or longer.

In many cases, the headspace oxygen of the containers useful for theinjectable compositions of this disclosure include (i) from about 0.5%v/v to about 5.0% v/v from the time of manufacture to about 6 monthsfrom manufacture when stored at temperatures from 25° C. to 60° C. or(ii) from about 0.5% v/v to about 10.0% v/v from the time of manufactureto about 6 months from manufacture when stored at temperatures from 25°C. to 60° C.; and the dissolved oxygen present in the injectablecomposition can be in an amount from about 0.1 parts per million (ppm)to about 9 ppm from the time of manufacture to about 1 month frommanufacture when stored at room temperature, wherein the composition isenclosed in a single-use container having a volume of from about 1 mL toabout 10 mL.

During a manufacturing process, in one embodiment, dissolved oxygenlevels are controlled via sparging with an inert gas. Additionally, ablanket of inert gas (e.g., nitrogen, argon, helium) can be maintainedthroughout manufacturing and storage to control atmospheric oxygenexposure, while an opaque container (stainless steel or amber glass) isselected to protect the formulation from exposure to light. In someembodiments, it was found that the trace elements injectable compositionof this application containing at least one of zinc, copper, manganeseand selenium or a mixture thereof, a USP injectable product, was notsensitive to oxygen and thus, a nitrogen blanket/sparging duringcompounding was not required during the manufacturing of the traceelements injectable composition.

In some embodiments, the injectable composition is preservative-free. Asused herein, preservative-free includes compositions that do not containany preservative. Thus, the composition does not contain, for example,benzalkonium chloride, methyl, ethyl, propyl or butylparaben, benzylalcohol, phenylethyl alcohol, or benzethonium.

In some embodiments, one or more preservatives can be incorporated intothe injectable pharmaceutical composition described in this disclosure,especially in a multi-dose injectable composition. Preservatives can beintroduced into a pharmaceutical solution to kill bacteria, yeast, andmold. The bacteria, yeast, and mold can be introduced accidentally whenmultiple aliquots are withdrawn from a container which holds multipledoses of a medicament.

A number of preservatives are available which can kill or prevent thegrowth of commonly encountered contaminants; these contaminants include,but are not limited to the bacteria P. aeruginosa, E. coli and S.aureus; the yeast C. albicans; and the mold A. brasiliensis. In variousembodiments, the preservative comprises benzyl alcohol in an amount of0.9% by weight based on a total weight of the injectable composition.

The preservative or preservatives are present in an amount which iseffective to impart the desired preservative characteristics and allowsthe final composition to comply with the European Pharmacopoeia 2011Test for Efficacy of Antimicrobial Preservation, satisfying at least theB criteria for parenterals, and the United States Pharmacopeia 2011Guidelines for Antimicrobial Effectiveness Testing for Category 1(injectable) products.

Method of Preparing the Injectable Compositions

The stable injectable compositions of the present application can bemade by mixing from about 900 μg to about 4,000 μg of zinc, from about40 μg to about 400 μg of copper, from about 4 μg to about 90 μg ofselenium, and from about 1 μg to about 80 μg of manganese with water toform 1 mL of the injectable composition. I

The components of the trace elements can be mixed in any order. Forexample, one or more trace elements can be added together and then mixedwith water to form a solution having the desired concentration. Themixed trace elements solution pH can be adjusted to a desired value andthen the pH adjusted solution can, optionally, be filtered through oneor more 0.22 μm sterile filters. The filtered solution can then befilled into the desired container to form the injectable trace elementssolution suitable for addition to a parenteral nutrition.

In some embodiments, the injectable compositions of one or more traceelements comprises, consists essentially of, or consists of 3,000 μg ofzinc, 300 μg of copper, 60 μg of selenium, and 55 μg of manganese per 1mL of the injectable composition. These trace element compositions areuseful for applications to adult and/or pediatric patients.

A pediatric patient includes a patient known to be less than 15 years ofage. In some embodiments, the pediatric patient has a weight of lessthan 36 kg, but greater than 10 kg of body weight.

In other embodiments, the stable injectable composition of one or moretrace elements comprises, consists essentially of, or consists of 1000μg of zinc, 60 μg of copper, 6 μg of selenium, and 3 μg of manganese per1 mL of the injectable composition. These trace element injectablecompositions are useful for applications to neonates.

A neonate includes an infant aged 1 month or younger. In someembodiments, the neonate is less than 10 kg of body weight.

In some embodiments, the new trace element compositions of the currentapplication have reduced amounts of zinc, copper, manganese and nodetectable chromium compared to the Multitrace®-5 concentrated, whilethe selenium amount is the same. For example, the amount of selenium forthe adult Multitrace®-5 concentrated composition and the newadult/pediatric composition is the same, which is 60 mcg/mL selenium.The other trace elements in the new adult/pediatric composition of thecurrent application are zinc, copper, and manganese, which are inreduced amounts—mainly 3000 mcg/mL zinc, 300 mcg/mL copper, 55 mcg/mLmanganese, and no detectable chromium compared to the Multitrace®-5concentrated composition as shown in Table 35.

In some embodiments, for the new neonatal composition, compared to theMultitrace®-4 neonatal composition, the zinc, copper, and manganese arein reduced amounts—mainly 1000 mcg/mL zinc, 60 mcg/mL copper, 3 mcg/mLmanganese compared to the Multitrace®-4 neonatal composition. However,the selenium for the new neonatal composition is 6 mcg/mL, which isincreased as shown in Table 35.

In some embodiments, both the new adult/pediatric composition and thenew neonatal composition have no detectable chromium, which is unlikeother commercially available compositions (e.g., ADDAMEL™,Multitrace®-5, and Multitrace®-4) as shown in Table 35.

In many aspects, the trace elements of the injectable composition areelemental metals, for example, the zinc is elemental zinc, the copper iselemental copper, the selenium is elemental selenium, the manganese iselemental manganese and the water is sterile water for injection. Inother aspects, the trace elements are sourced from salts of thesemetals. For example, the elemental zinc is from zinc sulfate or zincsulfate heptahydrate, the elemental copper is from cupric sulfate orcupric sulfate pentahydrate, the elemental manganese is from manganesesulfate or manganese sulfate monohydrate and the elemental selenium isfrom selenious acid. In these compositions, at least one of the zinccomprises from about 0.23 wt. percent to about 1.33 wt. percent, thecopper comprises from about 0.05 wt. percent to about 0.13 wt. percent,the manganese comprises from about 0.026 wt. percent to about 0.013 wt.percent, the selenium comprises from about 0.002 wt. percent to about0.02 wt. percent, or the water comprises from about 96 wt. percent toabout 98.5 of the injectable composition based on a total weight of theinjectable composition.

In many cases, in the trace elements injectable composition prepared bythe above method, the zinc is sourced from zinc sulfate heptahydrate ata dose of from about 2.5 to about 7 mg/day, the copper is sourced formcupric sulfate pentahydrate at a dose of from about 0.5 to about 1.5mg/day, the manganese is sourced from manganese sulfate monohydrate at adose of from about 0.15 to about 0.8 mg/day, and the selenium is sourcedfrom selenious acid at a dose of from about 20 to about 60 μg/day. Insome other embodiments, the method of preparing the trace elementscomposition of this disclosure provides an injectable composition wherethe zinc is zinc sulfate heptahydrate at a dose of from about 2.5 toabout 7 mg/day, the copper is cupric sulfate pentahydrate at a dose offrom about 0.5 to about 1.5 mg/day, the manganese is manganese sulfatemonohydrate at a dose of from about 0.015 to about 0.08 mg/day, and theselenium is sourced selenious acid at a dose of from about 20 to about60 μg/day. In some embodiments, selenious acid, is a weak acid and itcan form salts with metal oxides and hydroxides, such as potassium,zinc, copper, manganese, calcium, or molybdenum. It can also form saltswith ammonia (e.g., ammonium selenite) and organic bases.

In many instances the pH of the trace elements composition varies in arange from about 1.0 to about 9. In some instances, the pH of the traceelements composition can be about 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6,1.7, 1.8, 1.9, 2, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3, 3.1,3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1, 4.2, 4.3, 4.4, 4.5,4.6, 4.7, 4.8, 4.9, 5.0, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 6,6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7, 7.1, 7.2, 7.3, 7.4, 7.5,7.6, 7.7, 7.8, 7.9, 8.0, 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9 toabout 9.0.

In some embodiments, the pH of the trace elements composition can beadjusted using pH adjusting agents including organic or inorganic acidsand bases. Suitable acids include, but are not limited to, inorganicacids such as hydrochloric acid, hydrobromic acid, sulfuric acid, nitricacid, phosphoric acid or the like, and organic acids such as aceticacid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, maleicacid, malonic acid, succinic acid, fumaric acid, tartaric acid, citricacid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid,ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid or the like.Suitable inorganic bases include, but are not limited to, sodiumhydroxide, potassium hydroxide, K2CO3, Na2CO3, K3PO4, Na3PO4, K2HPO4,Na2HPO4, organic bases include salts of primary, secondary, and tertiaryamines, substituted amines including naturally occurring substitutedamines, cyclic amines, ethanolamine, 2-diethylaminoethanol, lysine,arginine, histidine or the like.

In various embodiments, gamma radiation is used in the terminalsterilization step, which involves utilizing ionizing energy from gammarays that penetrate deeply into a vial containing the injectablecomposition of this disclosure. Gamma rays are highly effective inkilling microorganisms, they leave no residues, nor do they havesufficient energy to impart radioactivity to the apparatus. Gamma rayscan be employed when the injectable composition is a vial or ampulebecause gamma ray sterilization does not require high pressures orvacuum conditions, and thus the container of the injectable compositionis not stressed.

In other embodiments, electron beam (e-beam) radiation may be used tosterilize the injectable composition described in this disclosure.E-beam radiation comprises a form of ionizing energy, which is generallycharacterized by low penetration and high-dose rates. E-beam irradiationis similar to gamma ray processing in that it alters various chemicaland molecular bonds on contact, including the reproductive cells ofmicroorganisms. Beams produced for e-beam sterilization areconcentrated, highly charged streams of electrons generated by theacceleration and conversion of electricity.

Autoclaving is usually performed in an autoclave. An autoclave usespressurized steam as their sterilization agent. The basic concept of anautoclave is to have each item sterilized—whether it is a liquid,plastic ware, or glassware—come in direct contact with steam at aspecific temperature and pressure for a specific amount of time. Time,steam, temperature, and pressure are the four main parameters requiredfor a successful sterilization using an autoclave.

The amount of time and temperature required for sterilization of a vialor ampule containing the injectable composition can use highertemperatures for sterilization and requires shorter times. The mostcommon temperatures used are 121° C. and 132° C. In order for steam toreach these high temperatures, steam has to be pumped into the chamberat a pressure higher than normal atmospheric pressure. In variousembodiments, a terminal sterilization feasibility study confirmed thatthe finished product is stable and can maintain its characteristics uponterminal sterilization. Thus, in various embodiments, the trace elementsinjectable compositions of this application are terminally sterilized at122.2° C. for 15 minutes.

The injectable compositions of the present disclosure are packaged inpharmaceutically acceptable containers. Pharmaceutically acceptablecontainers include intravenous bags, bottles, vials, and/or syringes. Incertain embodiments, the containers include intravenous bags andsyringes, which can be polymer-based, and vials and intravenous bottles,which can be made of glass. In some embodiments, the components of thecontainer that come into contact with the pharmaceutical composition donot contain polyvinylchloride (PVC). In various aspects, the containeris an intravenous bag that does not have any PVC containing componentsin contact with the pharmaceutical composition. It is also desirable toprotect the pharmaceutical compositions from light. Therefore, thecontainer may, optionally, further comprise a light barrier. In certainembodiments, the light barrier can be an aluminum over a pouch.

In many aspects, the present disclosure also provides methods forpreparing sterile pharmaceutical compositions. Examples of suitableprocedures for producing sterile pharmaceutical drug products include,but are not limited to, terminal moist heat sterilization, ethyleneoxide, radiation (i.e., gamma and electron beam), and aseptic processingtechniques. Any one of these sterilization procedures can be used toproduce the sterile pharmaceutical compositions described herein.

Sterile pharmaceutical compositions may also be prepared using asepticprocessing techniques. Sterility is maintained by using sterilematerials and a controlled working environment. All containers andapparatus are sterilized, preferably by heat sterilization, prior tofilling. Then, the container is filled under aseptic conditions, such asby passing the composition through a filter and filling the units.Therefore, the compositions can be sterile filled into a container toavoid the heat stress of terminal sterilization.

Method of Preparing Parenteral Nutrition

The trace elements of the current application include lower dailyamounts of at least one of zinc, copper, chromium and/or manganese per 1mL of the composition than currently available products.

In some embodiments, the trace elements composition contains little orno chromium. The chromium that is present can be present as an impurityand not to exceed about 1 μg and, in other aspects, not to exceed 0.5μg, in other embodiments, not to exceed about 0.25 μg/mL, and in otherembodiments, not to exceed 0.1 μg/mL. In other instances, the injectablecomposition contains from about 0.0001 μg/mL to about 0.25 μg/mL ofchromium. Therefore, when the trace element is added to the PN (e.g., PNof one liter or more), the PN will have no added chromium but may, insome embodiments, contain a chromium impurity from about 0.0001 μg/mL toabout 0.25 μg/mL, or in some embodiments, no chromium.

In some embodiments, the amount of chromium in the parenteral nutritioncontaining the trace elements composition or the trace elementscomposition itself is not more than about 0.15 μg/mL to not more thanabout 0.07 μg/mL or lower. With the not more than about 0.15 μg/mL ofchromium, the maximum potential exposure to chromium (e.g., 0.045μg/kg/day) will be 22.5% of the maximum chromium dose that can be usedfor parenteral nutrition in a target patient population (e.g., children(weighing 0.4-9.9 kg)). This can be based on a target dose volume of,for example, 0.3 mL/kg/day. In some embodiments, this will reduce therisk of toxicity from total chromium exposure in the parenteralnutrition (e.g., from intentionally added chromium and chromium as animpurity).

The trace elements in solution form can be added to the parenteralnutrition typically at a port of the parenteral nutrition containerusing aseptic technique and, optionally, under a laminar flow hood. Theparenteral nutrition can have essential and non-essential amino acids,dextrose, water, lipids, and/or electrolytes in it.

In many embodiments, a method of making a parenteral nutritioncontaining trace elements is provided. The method comprises adding traceelements to the parenteral nutrition, the trace elements comprisingabout 900 μg to about 4,000 μg of zinc, about 40 μg to about 400 μg ofcopper, about 4 μg to about 90 μg of selenium, and about 1 μg to about80 μg of manganese per 250 mL to about 4000 mL of the parenteralnutrition, the parenteral nutrition comprising at least one of aminoacid, a dextrose, a lipid, an electrolyte, or a mixture thereof. In somecases, the parenteral nutrition obtained by this method contains 3,000μg of zinc, 300 μg of copper, 60 μg of selenium, and 55 μg of manganeseper 250 mL to about 4000 mL of the parenteral nutrition. In other cases,the parenteral nutrition obtained by this method contains 1000 μg ofzinc, 60 μg of copper, 6 μg of selenium, and 3 μg of manganese per 1 mLof the injectable composition per 250 mL to about 4000 mL of theparenteral nutrition.

In yet other cases, in the parenteral nutrition the zinc comprises zincsulfate or zinc sulfate heptahydrate in an amount of about 13.1 mg toabout 13.3 mg, the copper comprises cupric sulfate or cupric sulfatepentahydrate in an amount of about 1.1 mg to about 1.2 mg, the manganesecomprises manganese sulfate or manganese sulfate monohydrate in anamount of about 0.16 mg to about 0.18 mg and the selenium comprisesselenious acid in an amount of about 95 μg to about 99 μg per about 250mL to 4000 mL of parenteral nutrition. In another embodiment, theparenteral nutrition obtained by this method comprises zinc sulfate orzinc sulfate heptahydrate in an amount of about 13.2 mg, cupric sulfateor cupric sulfate pentahydrate of the parenteral nutrition in an amountof from about 1.179 mg, manganese sulfate or manganese sulfatemonohydrate in an amount of about 0.0169 mg and the selenious acid is inan amount of about 98 μg per 250 mL to 4000 mL of parenteral nutrition.

In some embodiment, there is a method of making a parenteral nutritioncontaining trace elements at least one of (i) the amino acid compriseslysine hydrochloride, phenylalanine, leucine, valine, threonine,methionine, isoleucine, tryptophan, alanine, arginine, glycine, proline,histidine, glutamic acid, serine, aspartic acid, tyrosine or a mixturethereof; (ii) the dextrose comprises dextrose monohydrate; (iii) thelipid comprises soybean oil, phospholipid, glycerin or a mixturethereof; or (iv) the electrolyte comprises sodium acetate trihydrate,potassium chloride, sodium chloride, potassium acetate, sodiumglycerophosphate anhydrous, magnesium sulfate heptahydrate, calciumchloride dihydrate, calcium gluconate or a mixture thereof. In theparenteral nutrition provided by this method, the dextrose comprisesdextrose 5%, dextrose 10%, dextrose 20%, dextrose 25%, or dextrose 50%in water.

The parenteral nutrition provided by this method is stable when storedfrom about 2° C. to about 8° C. for up to about 14 days. In manyinstances, when stored from about 2° C. to about 8° C. for about 14days, the parenteral nutrition maintained a pH from about 5.50 to about5.90 and, in some cases, a pH from about 4.5 to about 7.

In some embodiments, the 14 days stability is measured from the timewhen the trace elements composition is added at room temperature to theparenteral nutrition. In some embodiments, the 14 days stability ismeasured from the time when the trace elements composition is added atroom temperature to the parenteral nutrition and then stored underrefrigeration at 2° C. to about 8° C. In some embodiments, the 14 daysstability is measured from the time when the trace elements compositionis added at room temperature to the parenteral nutrition and about to beadministered to the patient, but is not and then is stored underrefrigeration at 2° C. to about 8° C. for the 14 days.

Further, when stored from about 2° C. to about 8° C. for about 14 days,the parenteral nutrition comprises at least one of (i) no more than 12particle per mL that are greater than 10 μm; or (ii) no more than 2particle per mL that are greater than 25 μm. In other cases, when storedfrom about 2° C. to about 8° C. for about 14 days, the parenteralnutrition did not exhibit microbial growth when in contact with bacteriasuch as S. aureus, P. aeruginosa, E. coli, C. albicans, A. brasiliensisor a mixture thereof.

Method of Use of the Injectable Compositions

After addition of the trace elements to the parenteral nutrition, theparenteral nutrition can then be connected to an IV tube set and theparenteral nutrition administered via infusion over the desired periodof time to the patient (e.g., 24 hours).

The parenteral nutrition can be used to provide a source of calories,protein, electrolytes, or essential fatty acids for adult patientsrequiring parenteral nutrition. In some embodiments, the method of thepresent application includes administering to a patient in need thereofan injectable parenteral nutrition formulation comprising at least oneof amino acid, a dextrose, a lipid, an electrolyte, or a mixturethereof. Therefore, one or more trace elements (e.g., zinc, copper,selenium, manganese) can be added to injectable amino acids, dextrose,water, lipids, electrolytes, or a combination thereof based on thespecific need of the patient.

The trace elements can be a single trace element (e.g., zinc alone) or acombination of trace elements (e.g., zinc, copper, selenium, manganese)that can be added to the injectable amino acids, dextrose, water,lipids, electrolytes or a combination thereof based on the specific needof the patient.

In various other embodiments, the parenteral nutrition comprises fromabout 900 μg to about 4,000 μg of zinc, from about 40 μg to about 400 μgof copper, from about 4 μg to about 90 μg of selenium, and from about 1μg to about 80 μg of manganese per 250 mL to 4000 mL of the parenteralnutrition. In some aspects, the parenteral nutrition comprises, consistsessentially of, or consists of 3,000 μg of zinc, 300 μg of copper, 60 μgof selenium, and 55 μg of manganese per 250 mL to about 4000 mL of theparenteral nutrition. In some aspects, the parenteral nutritioncomprises, consists essentially of, or consists of 1,000 μg of zinc, 60μg of copper, 6 μg of selenium, and 3 μg of manganese per 250 mL toabout 4000 mL of the parenteral nutrition.

In other aspects, the zinc comprises zinc sulfate or zinc sulfateheptahydrate in an amount of about 13.1 mg to about 13.3 mg, the coppercomprises cupric sulfate or cupric sulfate pentahydrate in an amount ofabout 1.1 mg to about 1.2 mg, the manganese comprises manganese sulfateor manganese sulfate monohydrate in an amount of about 0.16 mg to about0.18 mg and the selenium comprises selenious acid in an amount of about95 μg to about 99 μg per about 250 mL to 4000 mL of parenteralnutrition. In yet other aspects, the zinc sulfate or zinc sulfateheptahydrate is in an amount of about 13.2 mg, the cupric sulfate or thecupric sulfate pentahydrate is in an amount of about 1.179 mg, themanganese sulfate or manganese sulfate monohydrate is in an amount ofabout 0.169 mg and the selenious acid is in an amount of about 98 μg.

In many embodiments, the at least one of the amino acid useful in themethod of providing a source of calories comprises lysine hydrochloride,phenylalanine, leucine, valine, threonine, methionine, isoleucine,tryptophan, alanine, arginine, glycine, proline, histidine, glutamicacid, serine, aspartic acid, tyrosine or a mixture thereof. The dextroseuseful in this method includes dextrose monohydrate, anhydrous andhydrous forms of dextrose, for example, dextrose 5%, dextrose 10%,dextrose 20%, dextrose 25%, or dextrose 50% in water, or a combinationthereof. Useful lipids include without limitation soybean oil,phospholipid, glycerin, or a mixture thereof. The electrolyte cancomprise sodium acetate trihydrate, potassium chloride, sodium chloride,potassium acetate, sodium glycerophosphate anhydrous, magnesium sulfateheptahydrate, calcium chloride dihydrate, calcium gluconate or a mixturethereof.

In various aspects, the parenteral nutrition used in the method ofproviding a source of calories, protein, electrolytes, or essentialfatty acids is nonpyrogenic and can have a pH that can vary from about3.5 to about 7.9.

It has been surprisingly found that the parenteral nutrition used in themethod of providing a source of calories, protein, electrolytes, oressential fatty acids is stable when stored from about 2° C. to about 8°C. for up to about 14 days. In many aspects, the stable parenteralnutrition when stored from about 2° C. to about 8° C. for about 14 dayscan maintain a pH from about 5.50, 5.60, 5.70, 5.80 to about 5.90. Invarious instances, when stored from about 2° C. to about 8° C. for about14 days, the parenteral nutrition comprises at least one of (i) no morethan 12 particle per mL that are greater than 10 μm; or (ii) no morethan 2 particle per mL that are greater than 25 μm. Also, when stored atfrom about 2° C. to about 8° C. for about 14 days, the parenteralnutrition did not exhibit microbial growth caused by such microbes as,for example, S. aureus, P. aeruginosa, E. coli, C. albicans, A.brasiliensis or a mixture thereof.

In various embodiments, a method of maintaining plasma trace elements ina patient in need thereof is provided. The method of maintaining plasmatrace elements comprises administering at least an injectablecomposition to the patient, the injectable composition comprising water,from about 900 μg to about 4,000 μg of zinc, from about 40 μg to about400 μg of copper, from about 4 μg to about 90 μg of selenium, and fromabout 1 μg to about 80 μg of manganese per 1 mL of the injectablecomposition. In many aspects, when the injectable composition is storedfrom about 2° C. to about 8° C. for about 14 days, then the injectablecomposition comprises at least one of (i) no more than 12 particle permL that are greater than 10 μm; or (ii) no more than 2 particle per mLthat are greater than 25 μm. In other aspects, when stored from about 2°C. to about 8° C. for about 14 days, the injectable composition did notexhibit microbial growth caused by any one of several microbes, forexample, S. aureus, P. aeruginosa, E. coli, C. albicans, A. brasiliensisor a mixture thereof. In many cases, when stored from about 2° C. toabout 8° C. for about 14 days, the injectable composition maintained apH from about 5.50 to about 5.90.

In various embodiments, the method of maintaining plasma trace elementsin a patient in need thereof further comprises treating patients havinga negative nitrogen balance. In other embodiments, the method ofmaintaining plasma trace elements in a patient in need thereof furthercomprises the use of the electrolyte as a supplement to intravenoussolutions given for parenteral nutrition to maintain plasma levels ofanyone of zinc, copper, manganese or selenium or a mixture thereof toprevent depletion of endogenous stores of these trace elements andsubsequent deficiency symptoms.

These and other aspects of the present application will be furtherappreciated upon consideration of the following examples, which areintended to illustrate certain particular embodiments of theapplication, but they are not intended to limit its scope, as defined bythe claims.

EXAMPLES

Examples of the stable, ready-to-use injectable compositions containingtrace elements such as zinc, copper, selenium, and manganese aredescribed in some of the examples below. The examples also includeparenteral nutrition solutions with or without the stable injectablecompositions having trace elements such as zinc, copper, selenium, andmanganese. The trace elements of the current application include lowerdaily amounts of at least one of zinc, copper, chromium, and/ormanganese per 1 mL of the trace element solution than currentlyavailable products. When added to parenteral solution the parenteralsolution containing the trace elements remained stable for about atleast 3 days up to 14 days under refrigeration.

Example 1

In this example, an injectable sterile, nonpyrogenic solution includingtrace elements of zinc, copper, manganese, and selenium is prepared bymixing these elements with water for injection to form 1 mL ofinjectable composition per single dose vial. This composition containsnot more than 1.0 μg chromium in conformance with USP formulationrequirements. The formulation is summarized in Table 6.

TABLE 6 Injectable Composition Ingredient Name Quantity per mL ElementalEquivalent Zinc Sulfate•7H₂O, USP 13.20 mg 3 mg Zn/mL CupricSulfate•5H₂O, USP 1.18 mg 0.3 mg Cu/mL Manganese Sulfate•H₂O, USP 169.00mcg 55 μg Mn/mL Selenious Acid, USP 98.00 mcg 60 μg Se/mL Sulfuric Acid,NF N/A N/A Water for Injection, USP Q.S. to 1 mL N/A N/A = NotApplicable

Each mL contains: zinc sulfate, USP (heptahydrate) 13.20 mg (equivalentto 3 mg zinc); cupric sulfate, USP (pentahydrate) 1.18 mg (equivalent to0.3 mg copper); selenious acid, USP 98 μg (equivalent to 60 μgselenium); manganese sulfate, USP (monohydrate) 169 μg (equivalent to 55μg manganese); and water for injection, USP q.s. The pH range of thesolution is 1.5 to 3.5 and may be adjusted with sulfuric acid, NF.

Example 2

This example discusses studies of known parenteral nutrition admixedwith the injectable compositions of trace elements described in thisapplication. Studies of parenteral nutrition (PN) solutions admixed withthe injectable compositions of trace elements of this application wereconducted over a 3 day and 14-day interval. PN solutions used in thesestudies were CLINIMIX® and KABIVEN® as listed in Table 7 below.

TABLE 7 Parenteral Nutrition CLINIMIX E CLINIMIX E Type Ingredient4.25/25 4.25/10 KABIVEN ® Soybean Oil (g/100 mL) — — 3.9 DextroseHydrous, USP (g/100 mL) 25 10 9.8 Amino Acids (g/100 mL) 4.25 4.25 3.31Total Nitrogen (mg/100 mL) 702 702 526 Essential Leucine 311 311 263Amino Isoleucine 255 255 164 Acids Leucine — — 231 Valine 247 247 213Lysine (as the hydrochloride) 247 247 263 Phenylalanine 238 238 231Histidine 204 204 199 Threonine 179 179 164 Methionine 170 170 164Tryptophan 77 77 55 Nonessential Alanine 880 880 467 Amino AcidsArginine 489 489 330 (mg/100 mL) Glycine 438 438 231 Proline 289 289 199Serine 213 213 131 Aspartic Acid, USP — — 99 Tyrosine 17 17 6.7Electrolytes Sodium Acetate Trihydrate, USP 297 297 239 (mg/100 ml)Potassium Chloride — — 174 Sodium Glycerophosphate, — — 147 AnhydrousDibasic Potassium Phosphate, USP 261 261 — Sodium Chloride, USP 77 77 —Magnesium chloride, USP 51 51 — Magnesium Sulfate Heptahydrate, — — 96USP Calcium Chloride Dihydrate, USP 33 33 29 Electrolyte Sodium 35 35 31Profile Potassium 30 30 23 (mEq/L) Magnesium 5 5 7.8 Calcium 4.5 4.5 3.8(2.2 mmol/L) (2.2 mmol/L) (1.9 mmol/L) Acetate 70 70 38 Chloride 39 3945 Sulfate — — 7.8 Phosphate (as HP0₄) 30 30 N.A. (15 mmol/L) (15mmol/L) (9.7 mmol/L) pH range 6.0 6.0 5.6 (4.5 to 7.0) (4.5 to 7.0)Osmolarity (mOsmol/L) (calc.) 1825 1070 1060 From Dextrose 850 340 330From Lipid — — 390 From Amino Acids 170 170 130 Total (Dextrose, Lipidand Amino 1020 510 1060 Acids)

CLINIMIX E 4.25/25 contained 24% dextrose concentration and was used ina three (3)-day study. Because this formulation was discontinued,CLINIMIX E 4.25/10 which contained 10% dextrose concentration was usedin the 14-day study. The same KABIVEN® formulation described in Table 2was used in both 3-day and 14-day studies.

In these studies, 1 mL of the injectable trace element composition wasadded to two (2) L IV PN infusion bags of KABIVEN® and CLINIMIX E.KABIVEN® admixtures with and without 1 mL of Injectable trace elementcomposition were stored for about at least 3 days (72 hours) at 2-8° C.Upon testing as described below the KABIVEN® admixtures met theacceptance criteria of a “no growth” protocol. CLINIMIX E admixtureswith and without the introduction of Injectable trace elementcomposition found the admixtures stored for about at least 3 days (72hours) at either 2° C. to 8° C. or 20° C. to 25° C. met the acceptancecriteria of “no growth” protocol. Based on the results of theseadmixture studies, we concluded that the admixture of injectable traceelement composition in 2 L infusion PN solutions of KABIVEN® andCLINIMIX E supported the manufacturers' original package insert labelingrecommendations for KABIVEN® and CLINIMIX E.

For example, for KABIVEN®, the labeling recommendation states that“KABIVEN® should be used immediately after mixing and the introductionof additives. If not used immediately, the storage time and conditionsprior to use should not be longer than 24 hours at 2° to 8° C. (36° to46° F.). After removal from storage at 2° to 8° C. (36° to 46° F.), theadmixture should be infused within 24 hours. Any mixture remaining mustbe discarded.”

For CLINIMIX E the labeling recommendations caution “Use promptly aftermixing. Any storage with additives should be under refrigeration andlimited to a period, no longer than 24 hours. After removal fromrefrigeration, use promptly and complete the infusion within 24 hours.Any mixture remaining must be discarded.”

In order to establish stability data for parenteral nutrition admixedwith the injectable compositions of trace elements, we conducted astability study of injectable trace element composition (trace elementsinjectable composition, USP) in parenteral nutrition admixtures (assaytest); a pH study of parenteral nutrition (PN) admixtures upon additionof injectable trace element composition (trace elements injectablecomposition, USP); a compatibility study of injectable trace elementcomposition (trace elements injectable composition, USP) in parenteralnutrition admixtures; and a reduced inoculation antimicrobialeffectiveness study for injectable trace element composition (traceelements injectable composition, USP) in parenteral nutritionadmixtures.

These studies were intended to support the USP <797> medium risk storagefor up to 9 days under refrigeration [2° to 8° C. (36° to 46° F.)]. Atthe time of initiating the 14-day admixture studies, it was noted thatthe current package insert (PI) labeling of KABIVEN® and CLINIMIX nowincludes the following beyond use dating (BUD) statements for storage:

For KABIVEN®: In the absence of additives, once activated, KABIVEN®remains stable for 48 hours at 25° C. (77° F.). If not used immediately,the activated bag can be stored for up to 7 days under refrigeration [2°to 8° C. (36° to 46° F.)]. After removal from refrigeration, theactivated bag should be used within 48 hours. For CLINIMIX E: Storageafter removal of overwrap: once removed from the protective clearoverwrap, mixed (peel seal activated) or unmixed (peel seal intact),CLINIMIX E solutions may be stored under refrigeration for up to 9 days.The results or our studies are discussed in examples 3, below.

Example 3—Stability Study of Injectable Trace Element Composition (TraceElements Injectable Composition, USP) in Parenteral Nutrition AdmixturesAssay Test

In this example, we evaluated whether the addition of an injectabletrace element composition to parenteral nutrition (PN) admixtures wouldresult in chemical degradation of individual ingredients under theprescribed in-use condition of up to 14 days. The PN admixtures wereassay tested for zinc, copper, selenium, and manganese. Chromium wasevaluated as a potential elemental impurity.

In this example, control PN admixtures (e.g., without an injectabletrace element composition) of KABIVEN® and CLINIMIX E were tested fortrace element levels of zinc, copper, selenium, manganese, and chromiumand the findings are summarized in Tables 8 and 10 below. Tables 9 and11 illustrate assay results of a KABIVEN® and CLINIMIX E PN IV solutionstreated with the injectable trace element composition of thisapplication and stored 14 days at 2° C. to 8° C.

TABLE 8 Assay Results for KABIVEN ® Control Admixtures withoutInjectable Trace Element Composition Assay Zinc Copper SeleniumManganese Chromium Results <750 μg/L <75 μg/L <15 μg/L <13.7 μg/L <0.25μg/mL

TABLE 9 Assay Results for Injectable Trace Element Composition inKABIVEN ® Solution Stored 14 days at 2° C. to 8° C. Acceptance Day DayDay Day Day Assay Criteria 0 5 7 10 14 Zinc 90.0-110.0% 96.5 93.9 93.897.0 96.0 Copper 90.0-110.0% 101.8 98.7 97.8 99.9 105.5 Selenium90.0-110.0% 92.6 93.5 97.9 92.6 90.8 Manganese 90.0-110.0% 100.7 95.092.1 102.5 97.9

TABLE 10 Assay Results for CLINIMIX E Control PN Admixture withoutInjectable Trace Element Composition Assay Zinc Copper SeleniumManganese Chromium Results <750 μg/L <75 μg/L <15 μg/L <13.7 μg/L <0.25μg/L

TABLE 11 Assay Results for Injectable trace element composition inCLINIMIX Solution Stored for 14 days at 2° C. to 8° C. Acceptance AssayCriteria Day 0 Day 5 Day 7 Day 10 Day 14 Zinc 90.0-110.0%  98.5  94.4 96.5  96.2  96.3 Copper 90.0-110.0% 109.7  98.8 101.5 101.0 106.0Selenium 90.0-110.0% 108.8 102.0 104.2 101.2  95.7 Manganese 90.0-110.0%105.0  97.2  98.9 101.6 106.8

The results of this study show that assay values of parenteral nutritionsolutions of KABIVEN® and CLINIMIX E in two (2) L infusion solutionseach spiked with 1.0 mL of injectable trace element composition andstored under refrigeration (2° C. to 8° C.) remained within the protocolacceptance criteria of 90.0-110.0% acceptance criteria for the fourteen(14) day duration of the study.

Example 4—pH Study of Parenteral Nutrition (PN) Admixtures Upon Additionof Injectable Trace Element Composition (Trace Elements InjectableComposition)

In this example, a study was conducted to evaluate pH changes before andafter the addition of injectable trace element composition added to PNsolutions of KABIVEN® and CLINIMIX E. The study was conducted todetermine if the addition of the injectable trace element composition ofthis disclosure would significantly change the pH of the PN admixturesunder the prescribed in-use conditions. The pH measurements wereperformed at Day 0, Day 5, Day 7, Day 10 and Day 14 on samples stored at2° C. to 8° C. and the results are illustrated in Tables 12 and 13. Inthe assays summarized in Tables 9 and 10, the control sample is eitherKABIVEN® or CLINIMIX E PN mixture as found in an IV bag or TE-4represents a bag of KABIVEN® or CLINIMIX E to which 1.0 mL of injectabletrace element composition containing zinc, copper, selenium, andmanganese was added.

TABLE 12 pH Results for Injectable Trace Element Composition added toKABIVEN ® Solution Stored 14 days at 2° C. to 8° C. Acceptance Day 0 Day5 Day 7 Day 10 Day 14 Test Criteria Control TE-4 Control TE-4 ControlTE-4 Control TE-4 Control TE-4 pH Record 5.52 5.51 5.51 5.51 5.49 5.505.50 5.49 5.50 5.50 results Control = bag of KABIVEN ® TE-4 = bag ofKABIVEN ® with added 1.0 mL of injectable trace element compositionincluding Zn, Cu, Mn, and Se.

TABLE 13 pH Results for Injectable trace element composition added toCLINIMIX Solution Stored 14 days at 2° C. to 8° C. Acceptance Day 0 Day5 Day 7 Day 10 Day 14 Test Criteria Control TE-4 Control TE-4 ControlTE-4 Control TE-4 Control TE-4 pH Record 5.86 5.87 5.85 5.85 5.86 5.855.86 5.86 5.87 5.86 results Control = bag of CLINIMIX TE-4 = bag ofCLINIMIX with added 1.0 mL of Injectable trace element compositionincluding Zn, Cu, Mn, and Se.

The results of these studies illustrate that pH of KABIVEN® and CLINIMIXE PN solutions, each spiked with 1.0 mL of Injectable trace elementcomposition did not differ from the pH of their respective controlsamples. In addition, the pH of KABIVEN® control, CLINIMIX E and samplesspiked with injectable trace element composition was unchanged afterstorage under refrigeration from 2° C. to 8° C. for up to 14 days.

Based on the results of these studies, it can be concluded that theaddition of 1.0 mL of injectable trace element composition to the 2 Lsolution of KABIVEN® and/or CLINIMIX E will not alter the pH of the PNsolutions when stored for 14 days at refrigeration (2° C. to 8° C.).

Example 5—Compatibility Study of Injectable Trace Element Composition(Trace Elements Injectable Composition, USP) in Parenteral NutritionAdmixtures

The studies summarized in Tables 14, 15, 16 and 17 were initiated toassure that the injectable trace element composition of this disclosureand PN solutions of KABIVEN and CLINIMIX E are physically compatible.The PN admixtures with and without the injectable trace elementcomposition were tested for visual examination and particulate matter(PM) by means of USP <788> Method 2 (Microscopic Particle Count Test).The testing was performed at Day 0, Day 5, Day 7, Day 10, and Day 14 onsamples stored at 2-8° C.

TABLE 14 PM Results for Injectable trace element composition (TE-4) inKABIVEN ® Bags Stored 14 days at 2° C. to 8° C. Acceptance 0 days 5 days7 Days 10 days 14 Days Test Criteria Control TE-4 Control TE-4 ControlTE-4 Control TE-4 Control TE-4 Visual Precipitates NA Con- NA Con- NACon- NA Con- NA Con- Examination have not forms forms forms forms formsformed during the addition of Injectable trace element composition Theemulsion NA Con- NA Con- NA Con- NA Con- NA Con- has not forms formsforms forms forms separated. Particulate NMT 12 <1 <1 <1 <1 <1 <1 <1 <1<1 <1 Matter particles per <788>: 1 mL that Method 2 are ≥10 μm. Micro-NMT 2 <1 <1 <1 <1 <1 <1 <1 <1 <1 <1 scopic particles per 1 mL that are≥25 μm. Particle 100 μm (for 0 0 0 0 <1 <1 <1 <1 <1 <1 Countinformational Test purposes only) Control = bag of KABIVEN ® TE-4 = bagof KABIVEN ® with added 1.0 mL of injectable trace element compositionincluding Zn, Cu, Mn, and Se.

TABLE 15 Particle Categorization for Injectable trace elementcomposition in KABIVEN ® Bags Stored 14 days at 2° C. to 8° C. TestParticle Description Station Control TE-4  0 Days Major: dark particlesMajor: dark particles (10-50 μm) (10-40 μm) Minor: light particlesMinor: light particle (10-40 μm), (10-40 μm), polymeric polymeric (20-70μm) (20-70 μm) ≥100 μm: no particles noted ≥100 μm: no particles noted 5 Days Major: light particles Major: dark particles (10-80 μm) (10-70μm) Minor: dark particles Minor: light particles (10-70 μm), (10-70 μm),polymeric polymeric (30-80 μm) (60 μm) ≥100 μm: no particles noted ≥100μm: no particles noted  7 Days Major: dark particles Major: darkparticles (10-40 μm) (10-60 μm) Minor: light particles Minor: lightparticles (10-30 μm), (10-40 μm), polymeric polymeric (30- (30-50μm) >100 μm), fibrous (80 μm) ≥100 μm: fibrous (310 μm) ≥100 μm:polymeric (190 μm, 240 μm) 10 days Major: dark particles Major: darkparticles (10-40 μm) (10-40 μm) Minor: light particles Minor: lightparticles (10-60 μm), (10-50 μm), polymeric polymeric (20- (20- >100μm) >100 μm) ≥100 μm: fibrous ≥100 μm: polymeric (180 μm), (200 μm)polymeric (270 μm) 14 Days Major: dark particles Major: dark particles(10-80 μm) (10-70 μm) Minor: light particles Minor: light particles(10-40 μm), (10-80 μm), polymeric polymeric (20->100 μm) (20-90 μm) ≥100μm :polymeric ≥100 μm: no particles noted (290 μm, 170 μm, 140 μm, 210,250 μm, 200 μm) Control = bag of KABIVEN ® TE-4 = bag of KABIVEN ® withadded 1.0 mL of injectable trace element composition including Zn, Cu,Mn, and Se.

TABLE 16 Particulate Matter Results for Injectable Trace ElementComposition in CLINIMIX E Bags Stored 14 Days at 2° C. to 8° C.Acceptance 0 days 5 days 7 Days 10 days 14 Days Test Criteria ControlTE-4 Control TE-4 Control TE-4 Control TE-4 Control TE-4 VisualPrecipitates NA Con- NA Con- NA Con- NA Con- NA Con- Examina- have notforms forms forms forms forms tion formed during the addition ofinjectable trace element composition The emulsion NA Con- NA Con- NACon- NA Con- NA Con- has not forms forms forms forms forms separated.Particulate NMT 12 <1 <1 <1 <1 <1 1 1 1 <1 <1 Matter particles per<788>: 1 mL that Method 2 are ≥10 μm. Microscopic NMT 2 <1 <1 <1 <1 <1<1 <1 <1 <1 <1 Particle particles per Count 1 mL that Test are ≥25 μm.100 μm (for 0 <1 <1 <1 0 0 0 <1 <1 0 informational purposes only)Control = bag of CINIMIX E ™ TE-4 = bag of CINIMIX E with added 1.0 mLof Injectable trace element composition including Zn, Cu, Mn, and Se.

TABLE 17 Particle Categorization for Injectable trace elementcomposition in CUNIMIX E Bags Stored 14 Days at 2° C. to 8° C. TestParticle Description Station Control TE-4  0 Days Major: dark particles(10-60 μm) Major: dark particles (10-90 μm) Minor: light particles(10-70 μm), Minor: light particle (10-70 μm), polymeric polymeric (80μm), fibrous (90 μm) (80 μm) ≥100 μm: no particles noted ≥100 μm:fibrous (460 μm)  5 Days Major: dark particles (10-50 μm) Major: darkparticles (10-90 μm) Minor: light particles (10-40 μm), Minor: lightparticles (10-70 μm), polymeric polymeric (20-70 μm) (20 μm-60 μm) ≥100μm: fibrous (380 μm) ≥100 μm: fibrous (150 μm, 170 μm, 260 μm)  7 DaysMajor: dark particles (10-80 μm) Major: dark particles (10-80 μm) Minor:light particles (10-70 μm), Minor: light particles (10-90 μm), polymericpolymeric (20-60 μm) (20-90 μm) ≥100 μm: no particles noted ≥100 μm: noparticles noted 10 days Major: dark particles (10-80 μm) Major: darkparticles (10->100 μm) Minor: light particles (10-70 μm), Minor: lightparticles (10-80 μm), polymeric polymeric (20-90 μm) (70 μm) ≥100 μm: noparticles noted ≥100 μm: dark particle (160 μm) 14 Days Major: darkparticles (10-50 μm) Major: dark particles (10-50 μm) Minor: lightparticles (10-90 μm), Minor: light particles (10-80 μm), polymericpolymeric (20-90 μm), fibrous (30- (20-80 μm) ≥100 μm) ≥100 μm: noparticles noted Control = bag of CINIMIX E TE-4 = bag of CINIMIX E withadded 1.0 mL of Injectable trace element composition including Zn, Cu,Mn, and Se.

The compatibility study results for both, the control and admixturesamples illustrated in Tables 14, 15, 16 and 17 indicated thatparticulate matter in these samples remained within USP <788> limits forlarge volume parenteral solutions. In addition, the consistency of theparticle counts and particle morphologies of the control and injectabletrace element composition admixture samples, demonstrated no evidence ofincompatibility.

Based on the results of this study, injectable trace element compositioncontaining zinc, copper, selenium, and manganese of this application iscompatible with KABIVEN® and CLINIMIX E solutions when stored for 14days at refrigeration (2° C. to 8° C.).

Example 6—Reduced Inoculation Antimicrobial Effectiveness Study forInjectable Trace Element Composition (Trace Elements InjectableComposition, USP) in Parenteral Nutrition Admixtures

In this example, the purpose of the reduced inoculation antimicrobialeffectiveness study was to demonstrate whether or not there would beadventitious microbial contamination growth during the preparation andstorage of parenteral nutrition admixtures with injectable trace elementcomposition containing zinc, copper, selenium and manganese. The PNadmixtures of Kobiven® and CLINIMIX E treated with injectable traceelement composition were challenged with five appropriate compendialmicroorganisms (i.e., Escherichia coli, Pseudomonas aeruginosa,Staphylococcus aureus, Candida albicans, and Aspergillus brasiliensis)at low inoculum levels 10-100 colony forming units/mL (CFU) for up to 14days at 2-8° C. storage conditions.

It is noted that the inoculum concentration of Candida albicans exceededprotocol upper limit of 100 CFU/mL (obtained 120 CFU/mL) had a reportedLog CFU recovery of 2.1. There was no impact on the study as the Log CFUrecoveries which were accurately enumerated at each time point of thestudy.

At each test point, the Log CFU recovery values were measured, were10-100 CFU is equivalent to 1-2 Log CFU. The acceptance criteria of theprotocol was “no growth” which was defined as not more than 0.5 logincreases from the calculated inoculum concentration. The results intables 18, 19, 20, 21, 22, 23, 24, and 25 are reported as Log CFU/mL ofproduct.

TABLE 18 Log Recovery Values for KABIVEN ® Admixture Bags withInjectable Trace Element Composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8  1.71.8 1.9 1.9 1.8 P. aeruginosa (9027) 1.6  1.8 0.9 0.8 0.5 0.5 E. coli(8739) 2.0  2.1 1.9 1.8 1.6 1.6 C. albicans (10231) 2.1^(a) 2.1 2.0 2.02.0 2.0 A. brasiliensis 1.4  1.5 1.4 1.2 1.2 1.2 (16404) NegativeProduct N/A <0.0 <0.0 <0.0 <0.0 <0.0 (TSA) Negative Product N/A <0.0<0.0 <0.0 <0.0 <0.0 (SDA) ^(a)Inoculum concentration exceeded protocollimit of 100 CFU/mL (obtained 120 CFU/mL). There was no impact on thestudy.

TABLE 19 Log Reduction Values for KABIVEN ® Admixture Bags withInjectable Trace Element Composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8  −0.1  0.0 +0.1 +0.1   0.0 P. aeruginosa 1.6  +0.2 −0.7 −0.8 −1.1 −1.1 (9027)E. coli (8739) 2.0  +0.1 −0.1 −0.2 −0.4 −0.4 C. albicans 2.1^(a)   0.0−0.1 −0.1 −0.1 −0.1 (10231) A. brasiliensis 1.4  +0.1   0.0 −0.2 −0.2−0.2 (16404) ^(a)Inoculum concentration exceeded protocol limit of 100CFU/mL (obtained 120 CFU/mL). There was no impact on the study.

TABLE 20 Log Recovery Values for KABIVEN ® Admixture Bags withoutInjectable trace element composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8    2.0  1.8   1.9   2.0   1.8 P. aeruginosa 1.6    1.6   0.8   0.5   0.6   0.5(9027) E. coli (8739) 2.0    2.1   1.9   1.9   1.9   1.6 C. albicans(10231) 2.1^(a)   2.0   2.0   2.0   2.1   2.1 A. brasiliensis 1.4    1.5  1.1   1.3   1.3   1.3 (16404) Negative Product N/A <0.0 <0.0 <0.0 <0.0<0.0 (TSA) Negative Product N/A <0.0 <0.0 <0.0 <0.0 <0.0 (SDA)^(a)Inoculum concentration exceeded protocol limit of 100 CFU/mL(obtained 120 CFU/mL). There was no impact on the study.

TABLE 21 Log Reduction Values for KABIVEN ® Admixture Bags withoutInjectable Trace Element Composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8  +0.2  0.0 +0.1 +0.2   0.0 P. aeruginosa 1.6    0.0 −0.8 −1.1 −1.0 −1.1(9027) E. coli (8739) 2.0  +0.1 −0.1 −0.1 −0.1 −0.2 C. albicans (10231)2.1^(a) −0.1 −0.1 −0.1 −0.0   0.0 A. brasiliensis 1.4  +0.1 −0.3 −0.1−0.1 −0.1 (16404) ^(a)Inoculum concentration exceeded protocol limit of100 CFU/mL (obtained 120 CFU/mL). There was no impact on the study.

KABIVEN® (contains dextrose, essential and nonessential amino acids withelectrolyte and a 20% lipid emulsion) with and without injectable traceelement composition containing zinc, copper, manganese and selenium werestored for up to 14 days at 2° C. to 8° C. met the protocol's acceptancecriteria of “no growth.” The marginally higher inoculum concentration ofC. albicans did not enhance any microbial proliferation within theproduct.

TABLE 22 Log Recovery Values for CLINIMIX E Admixture Bags (containsessential and non-essential amino acids with electrolyte in dextrosewith calcium) with Injectable trace element composition (2° C. to 8° C.)Organism (ATCC) Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus(6538) 1.8    1.9   1.8   1.8   1.8   1.7 P. aeruginosa 1.6    1.9   0.9  1.1   1.0   0.7 (9027) E. coli (8739) 2.0    2.0   1.6   1.4   1.2  1.0 C. albicans 2.1^(a)   2.0   2.0   2.0   1.9   1.9 (10231) A.brasiliensis 1.4    1.5   1.3   1.3   1.3   1.3 (16404) Negative ProductN/A <0.0 <0.0 <0.0 <0.0 <0.0 (TSA) Negative Product N/A <0.0 <0.0 <0.0<0.0 <0.0 (SDA) ^(a)Inoculum concentration exceeded protocol limit of100 CFU/mL (obtained 120 CFU/mL). There was no impact on the study.

TABLE 23 Log Reduction Values for CLINIMIX E Admixture Bags withInjectable trace element composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8  +0.1  0.0   0.0   0.0 −0.1 P. aeruginosa 1.6  +0.3 −0.7 −0.5 −0.6 −0.9(9027) E. coli (8739) 2.0    0.0 −0.4 −0.6 −0.8 −1.0 C. albicans 2.1^(a)−0.1 −0.1 −0.1 −0.2 −0.2 (10231) A. brasiliensis 1.4  +0.1 −0.1 −0.1−0.1 −0.1 (16404) ^(a)Inoculum concentration exceeded protocol limit of100 CFU/mL (obtained 120 CFU/mL). There was no impact on the study.

TABLE 24 Log Recovery Values for CLINIMIX E Admixture Bags withoutInjectable Trace Element Composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8 2.1 1.91.8 1.8 1.7 P. aeruginosa 1.6 1.7 1.1 0.8 0.7 0.5 (9027) E. coli (8739)2.0 2.0 1.6 1.5 1.3 1.0 C. albicans (10231) 2.1^(a) 2.0 1.9 1.9 1.9 1.9A. brasiliensis 1.4 1.5 1.2 1.2 1.3 1.3 (16404) Negative Product N/A<0.0 <0.0 <0.0 <0.0 <0.0 (TSA) Negative Product N/A <0.0 <0.0 <0.0 <0.0<0.0 (SDA) ^(a)Inoculum concentration exceeded protocol limit of 100CFU/mL (obtained 120 CFU/mL). There was no impact on the study.

TABLE 25 Log Reduction Values for CLINIMIX E Admixture Bags withoutInjectable Trace Element Composition (2° C. to 8° C.) Organism (ATCC)Inoculated Time 0 Day 5 Day 7 Day 10 Day 14 S. aureus (6538) 1.8  +0.3−0.1   0.0   0.0 −0.1 P. aeruginosa 1.6  +0.1 −0.5 −0.8 −0.9 −1.1 (9027)E. coli (8739) 2.0    0.0 −0.4 −0.5 −0.7 −1.0 C. albicans 2.1^(a) −0.1−0.2 −0.2 −0.2 −0.2 (10231) A. brasiliensis 1.4  +0.1 −0.2 −0.2 −0.1−0.1 (16404) ^(a)Inoculum concentration exceeded protocol limit of 100CFU/mL (obtained 120 CFU/mL). There was no impact on the study.

The Log recovery values results of CLINIMIX E IV admixtures with andwithout injectable trace element composition containing zinc, copper,selenium and manganese found that admixtures stored for up to 14 days at2° C. to 8° C. met the protocol's acceptance criteria of “no growth.”

The results of the reduced inoculation AME study, found both KABIVEN®and CLINIMIX E admixtures with and without the introduction ofinjectable trace element composition and stored for up to 14 days underrefrigeration (2° C. to 8° C.) met the protocol's acceptance criteria of“no growth.”

Since the results of the four-admixture studies met our acceptancecriteria, we concluded that the addition of injectable trace elementcomposition to either 2 L infusion solution (KABIVEN® and/or CLINIMIX E)supports the manufacturers' current package insert (PI) labeling of bothKABIVEN® and CLINIMIX E that the PN admixtures are stable for up to 9days when kept under refrigeration. As a result, a package insert forthe injectable trace element composition of this invention can includethe following USP <797> medium-risk BUD statements for package insertfor refrigerated storage up to 9 days.

Therefore, the package insert for injectable trace element compositionhas been revised to include the following storage recommendation: “Useparenteral nutrition solutions containing injectable trace elementcomposition promptly after mixing. Any storage of the admixture shouldbe under refrigeration from 2° C. to 8° C. (36° F. to 46° F.) andlimited to a period, no longer than 9 days. After removal fromrefrigeration, use promptly and complete the infusion within 24 hours.Discard any remaining admixture.” This package insert statement, inconjunction with our 14-day admixture studies at 2° to 8° C., nowprovide healthcare professionals, pharmacists and end-users extensiveadmixture stability information for selenious acid injection, USP, zincsulfate injection, USP, and injectable trace element compositioncontaining zinc, copper, manganese and selenium (Trace elementsinjectable composition, USP) in parenteral nutrition infusion solutionsunder refrigeration [2° to 8° C. (36° to 46° F.)].

Example 7—Process for Preparing Trace Elements Injectable Compositions

Three exhibit batches (lot RD15-013, RD16-001, RD16-007) and bridgingbatch (lot RD18-007) of the trace elements injectable composition, USPformulation were prepared utilizing the equipment and process parameterssummarized in Table 26 below.

TABLE 26 Process Parameters for Injectable Composition ManufacturingTrain and Process Parameters Concentration Zinc: 3 mg/mL Copper: 0.3mg/mL Selenium: 60 mg/mL Manganese: 55 μg/mL Batch Size 60 LitersFormulation Vessel T-8 Operating Volume of 30-100 L Fixed Speed Mixer:290 rpm/minute Mixing Time for Addition of APIs NLT 10 minutes ZincSulfate•7H₂O, USP Cupric Sulfate•5H₂O, USP Manganese Sulfate•H₂O, USPSelenious Acid, USP to Initial Water for Injection Charge Mixing Timefor pH Adjustment(s) NLT 10 minutes Mixing Time (post initial Q.S.) NLT15 minutes Mixing Time (post final Q.S.) NLT 15 minutes Bulk HoldingTime 48 hours Pre-Filter 10″ Pall Profile II (Polypropylene filament)1.0 micron (ID: AB1Y0107PH4) Filling Line 1 or 3 Sterilizing FilterType, Size, Pall Ultipor N₆₆ 0.2 and Model Number Micron Filter, Size 4″ID: MCY4440NFPH4-4″ Number of Sterilizing Filters to Use 1 FilterPriming Volume NLT 1.0 Liter Receiving Vessel 45 L Pyrex Glass CarboyContainer: USP Type I FV02T13G33 glass vial, Gerresheimer Gx33 Stopper:West 4432 FluroTec B2-40 ST13WB4432FLRS Fill Volume 1 mL Nitrogen FlushNo Terminally Sterilized Yes Autoclave Cycle 122.2° C. for 15 minutesNTL refers to not less than.

The compounding procedure described below was followed for a 60 L batch.A 50 L USP bulk tank (range 45-55 L) was charged with of water forinjection (WFI). A mixer (Fixed Speed: 290 RPM) was turned on and thetemperature was recorded. The mixer was turned off and specified amountsof USP Zinc Sulfate•7H₂O, Cupric Sulfate•5H₂O, Manganese Sulfate•H₂O andSelenious Acid were added into the bulk tank.

The bulk tank was closed and mixing continued for a minimum of 10minutes (range 10 to 15 minutes) or until dissolved. At the completionof mixing, the mixer was stopped, the tank opened, and the bulk productwas visually inspected to ensure complete dissolution. Approximately 50mL of the bulk solution was taken and checked for pH at 25° C.±2° C. Thetarget pH was 2.0 (range 1.9 to 2.1). If the pH of the bulk solution wasnot 2.0 (range 1.9 to 2.1), the pH was slowly adjusted with 10% v/vsulfuric acid solution to a target pH of 2.0 (range 1.9 to 2.1) andmixed for a minimum of 10 minutes (10 to 15 minutes) after each pHadjustment solution.

The mixer was turned off and the bulk solution Q.S. to 60 Liters withWater for Injection, USP. Tank was closed, and the bulk solution mixedfor a minimum of 15 minutes (range 15 to 20 minutes).

Mixing was continued while cooling the bulk to 25° C.±2° C. Mixer wasturned off, the tank opened and re-verified Q.S., otherwise more waterfor injection USP was added, if necessary. If additional WFI, USP wasadded, tank was closed, and bulk solution was mixed for a minimum of 15minutes (typical range 15 to 20 minutes). If no additional water wasadded, tank was closed, and this step marked as N/A. At end of mixing,the bulk tank was opened, approximately 50 mL of the bulk solutioncollected, and the pH checked at 25° C.±2° C. Target pH was 2.0 (range1.9 to 2.1). If the pH was not 2.0 (range 1.9 to 2.1) pH was slowlyadjusted with 10% v/v sulfuric acid solution to a target pH of 2.0(range 1.9 to 2.1). Bulk was mixed for a minimum of 10 minutes (10 to 15minutes) after each pH adjustment solution.

Following the above compounding, in-process chemistry samples were takenand analyzed. The in-process results for the four exhibit batches areprovided in Table 27:

TABLE 27 In-Process Results Results Test Specifications RD15-013RD16-001 RD16-007 RD18-007 Specific Gravity Report Result 1.009 g/mL1.009 g/mL 1.009 g/mL 1.009 g/mL pH 1.9 to 2.1  2.0 2.0 2.0 2.0 Assay -Zinc 93.0% to 107.0% 99.5% 102.2% 100.8% 99.2% Assay - Copper 93.0% to107.0% 101.5% 104.7% 103.5% 102.2% Assay - Selenium 93.0% to 107.0%96.3% 96.3% 98.1% 98.6% Assay - 93.0% to 107.0% 95.9% 99.8% 99.1% 99.1%Manganese

Prior to transferring the bulk into the aseptic processing area (APA), asample of the bulk solution (approximately 100 mL) was taken andsubmitted to for bioburden testing. The results are provided in Table28.

TABLE 28 Bioburden Results Specifi- Results Test cations* RD15-013RD16-001 RD16-007 RD18-007 Bioburden NMT 10 <1 <1 <1 <1 CFU/mL CFU/mLCFU/mL CFU/mL CFU/mL CFU refers to colony forming units.

A pre-use water bubble point test was performed on the sterilizing gradefilter to verify the integrity of the filter. Subsequently, the bulkproduct was passed through a 10″ 1.0 μm pre-filter and transfer line tothe filling room. It was continuously filtered through one 4″ 0.2 μmfilter and was supplied into a sterile receiving vessel in the APAFilling Line 1 or Line 3. The filtered bulk solution was filled into 2mL Type I, sulfur treated flint glass tubular vials with 13 mm neckopenings. The filled units were then stoppered with 13 mm gray West4432, B2-40 stoppers, and sealed with 13 mm West aluminum flip-off sealswith caps. A post-filtration bubble point test was performed to checkthe integrity of the sterilizing-grade filter.

USP lots RD15-013, RD16-001, RD16-007, and RD18-007 were filled as a 1mL fill in a 2 mL vial. Twelve consecutively filled vials were takenfrom the beginning, middle and end of the fill runs and gravimetricallytested to confirm fill volumes. The fill volume check sampling andresults are summarized in Table 29.

TABLE 29 Fill Volume Results Minimum: 1.16 g (1.15 mL)/Target: 1.31 g(1.3 mL)/Maximum: 1.41 g (1.4 mL) Acceptance Lot # RD15-013 Lot #RD16-001 Lot # RD16-007 Lot # RD18-007 Criteria Beg Mid End Beg Mid EndBeg Mid End Beg Mid End Average (g) 1.34 1.31 1.31 1.36 1.30 1.30 1.361.31 1.31 1.29 1.28 1.28 Intra-lot Average = 1.32 g Average = 1.32 gAverage = 1.33 g Average = 1.28 g Results (RSD = 2.7%) (RSD = 3.2%) (RSD= 2.3%) (RSD = 1.8%)

Each tray of filled vials was loaded into an autoclave and the finishedproduct was sterilized by autoclaving at 122.2° C. for 15 minutes.Following sterilization, the units were 100% inspected. A summary of thespecifications and test results for the three exhibit batches and onebridging batch are provided in the Table 30.

Appropriate stability studies were initiated, and the required number ofunits of each exhibit batch were placed into storage at 25° C./60% RH,30° C./65% RH, and 40° C./75% RH.

TABLE 30 Release Test Results for Trace Elements Injectable CompositionExhibit Exhibit Exhibit Bridging Batch Batch Batch Batch Test AcceptanceCriteria RD15-013 RD16-001 RD16-007 RD18-007 Description Clear,colorless to Pass Pass Pass Pass slightly blue solution and isessentially free from visible particulates. Identification A. Zinc - TheAssay Pass Pass Pass Pass preparation, prepared as directed in theAssay, exhibits an emission maximum at 472.215 nm when tested asdirected for Procedure in the respective Assay. B. Copper - The AssayPass Pass Pass Pass preparation, prepared as directed in the Assay,exhibits an emission maximum at 224.700 nm when tested as directed forProcedure in the respective Assay. C. Selenium - The Pass Pass Pass PassAssay preparation, prepared as directed in the Assay, exhibits anemission maximum at 196.026 nm when tested as directed for Procedure inthe respective Assay. D. Manganese - The Pass Pass Pass Pass Assaypreparation, prepared as directed in the Assay, exhibits an emissionmaximum at 279.827 nm when tested as directed for Procedure in therespective Assay. pH <791> Between 1.5 2.0 2.0 2.0 2.0 and 3.5. AssayZinc: It contains not 99.0% 102.4% 101.7% 98.3% less than 90.0% and notmore than 110.0% of the labeled amount of Zn. (L.C. = 0.3 mg/mL of Zinc)Copper: It contains 101.8% 103.9% 104.6% 101.5% not less than 90.0% andnot more than 110.0% of the labeled amount of Cu. (L.C. = 0.3 mg/mL ofCopper) Manganese: It 96.6% 99.0% 99.3% 97.8% contains not less than90.0% and not more than 110.0% of the labeled amount of Mn. (L.C. = 55μg/mL of Manganese) Selenium: It contains 96.3% 96.8% 98.6% 98.3% notless than 90.0% and not more than 110.0% of the labeled amount of Se.(L.C. = 60 μg/mL of Selenium) Residual <467> Meets Meets Meets MeetsMeets Solvents requirements under requirements requirements requirementsrequirements Option 2 Aluminum* Not more than 6,000 <1250 μg/L <1250μg/L <1250 μg/L <1250 μg/L (GFAAS) μg/L. Aluminum Not more than 6,000<1880 μg/L <1880 μg/L <1880 μg/L <1880 μg/L (ICP-MS) μg/L. ElementalArsenic: Not <0.45 <0.45 <0.45 <0.45 Impurities: more than 1.5 μg/mLμg/mL μg/mL μg/mL μg/mL Cadmium: Not <0.2 μg/mL <0.2 μg/mL <0.2 μg/mL<0.2 μg/mL more than 0.6 μg/mL Mercury: Not <0.1 μg/mL <0.1 μg/mL <0.1μg/mL <0.1 μg/mL more than 0.4 μg/mL Lead: Not <0.2 μg/mL <0.2 μg/mL<0.2 μg/mL <0.2 μg/mL more than 0.5 μg/mL Chromium: Not <0.3 μg/mL <0.3μg/mL <0.3 μg/mL <0.3 μg/mL more than 1.0 μg/mL Iron: Not <3 μg/mL <3μg/mL <3 μg/mL <3 μg/mL more than 10 μg/mL Silicon: <30 μg/mL <30 μg/mL<30 μg/mL <30 μg/mL Not more than 100 μg/mL Magnesium: Not <15 μg/mL <15μg/mL <15 μg/mL <15 μg/mL more than 50 μg/mL Calcium: Not <15 μg/mL <15μg/mL <15 μg/mL <15 μg/mL more than 50 μg/mL Boron: Not <15 μg/mL <15μg/mL <15 μg/mL <15 μg/mL more than 50 μg/mL Volume of 1 mL vial: Notless 1.3 mL 1.3 mL 1.3 mL 1.2 mL Solution than 1.0 mL. Particulate <788>Meets 1 8 4 1 Matter requirements of the <1 <1 <1 0 Light ObscurationParticle Count Test for small-volume injections, limits are: NMT 6,000particles ≥10 μm per container NMT 600 particles ≥25 μm per container Ifretested by the Microscopic method limits are: NMT 3,000 particles ≥10μm per container NMT 300 particles ≥25 μm per container Sterility <71>If no growth is No growth No growth No growth No growth observed, thearticle tested meets the requirements of the test for sterility.Bacterial <85> The Endotoxin <17.50 <17.50 <17.50 <17.50 Endotoxinslimit is not more than EU/mL EU/mL EU/mL EU/mL 50 EU/mL. Other Meetsrequirements N/A N/A N/A N/A requirements Current USP <1> *Aluminum wastested by both, GFAAS (graphite furnace atomic absorption spectroscopy)and ICP-MS (inductively coupled plasma mass spectrometry) methods,during the ICP-MS method development and validation.

Example 8—Stability Tests

In this example, the trace elements injectable compositions, USP lotsRD15-013, RD16-001, RD16-007, and RD18-007 were subjected to stabilityprotocols as summarized in Table 31.

TABLE 31 Stability Protocols Stability Storage Condition Test Station(Month) Finished Product release Initial (0) Upright 25 ± 2° C./60% RH ±5% RH 3, 6, 9, 12, 18, 24 Inverted 25 ± 2° C./60% RH ± 5% RH 3, 6, 9,12, 18, 24 Upright 40 ± 2° C./75% RH ± 5% RH 1, 3, 6 Inverted 40 ± 2°C./75% RH ± 5% RH 1, 3, 6

From the collected data, it can be seen that after 6-month exposure to40° C./75% RH and 24-month exposure to 25° C./60% RH conditions, allresults were stable, and met the stability specifications. The stabilitydata confirms that the manufacturing process and container closurecomponents chosen for the manufacture of the trace elements injectablecomposition, USP were acceptable. Based on the results of the 24-monthstability studies and acceptable 6-month accelerated stability resultsfor the exhibit batches, we concluded that the trace elements injectablecomposition, USP had a 24-month expiration dating.

On the trace elements injectable composition of this application, wealso conducted photostability studies. The stability storage conditionsand exposure criteria for the drug product photostability study aresummarized in the following table (Table 32) in accordance with the ICHQ1B Photostability Testing Guideline recommendations.

TABLE 32 Photostability Recommendations Storage Condition Exposure 25°C. ± 2° C., Horizontal, Not less than Visible Light Exposure 1.2 millionlux hours 25° C. ± 2° C., Horizontal, Not less than Near Ultraviolet(UV) Light 200-watt hours/m² Exposure

The protocol was designed to evaluate the drug product in its immediatepackaging system under light exposure by studying the following qualityattributes: pH, assay, elemental impurities, description, andparticulate matter. The finished product samples from the exhibit batchLot RD15-013 were used for this study. Photostability results for thevisible and UV light exposures are provided in Tables 33 and 34,respectively.

TABLE 33 Photostability Results for Visible Light Exposure Shelf I-Control Wrapped Test Name Specifications Initial¹ Shelf I Vials VisibleLight NLT 1.2 0 1.36 1.36 Exposure (million lux hours) Description²Conforms Conforms Conforms Conforms pH 1.5-3.5 2.0 2.0 2.0 Copper Assay90.0-110.0 (%) 103.0 102.0 102.3 Manganese Assay 90.0-110.0 (%) 97.896.8 97.6 Zinc Assay 90.0-110.0 (%) 100.7 99.6 100.4 Selenium Assay90.0-110.0 (%) 96.5 97.5 97.3 Aluminum Test NMT 6000 (μg/L)³ <1250 <1250<1250 (GFAA) Aluminum NMT 6000 (μg/L)³ <1880 <1880 <1880 (ICP-MS)Silicon NMT 100 (μg/mL) <30 <30 <30 Magnesium NMT 50 (μg/mL) <15 <15 <15Calcium NMT 50 (μg/mL) <15 <15 <15 Boron NMT 50 (μg/mL) <15 <15 <15Particulate NMT 6000 1 3 1 Matter (particles/container) 10 μmParticulate NMT 600 <1 <1 <1 Matter (particles/container) 25 μm

TABLE 34 Photostability Results for UV Light Exposure Shelf I-ControlWrapped Test Name Specifications Initial¹ Shelf I Vials UV Light NLT 200(w/m²) 0 422.34 422.34 Exposure Description² Conforms Conforms ConformsConforms pH 1.5-3.5 2.0 2.0 2.0 Copper Assay 90.0-110.0 (%) 103.0 102.3102.2 Manganese Assay 90.0-110.0 (%) 97.8 96.8 97.1 Zinc Assay90.0-110.0 (%) 100.7 100.0 99.9 Selenium Assay 90.0-110.0 (%) 96.5 93.594.8 Aluminum Test NMT 6000 <1250 <1250 <1250 (GFAA) (μg/L)³ AluminumNMT 6000 <1880 <1880 <1880 (ICP-MS) (μg/L)³ Silicon NMT 100 <30 <30 <30(μg/mL) Magnesium NMT 50 (μg/mL) <15 <15 <15 Calcium NMT 50 (μg/mL) <15<15 <15 Boron NMT 50 (μg/mL) <15 <15 <15 Particulate NMT 6000 1 1 1Matter (particles/ 10 μm container) Particulate NMT 600 <1 <1 <1 Matter(particles/ 25 μm container) ¹Samples not stored in the photostabilitychamber. ²Clear colorless to slightly blue solution and is essentiallyfree from visible particulates. ³Limit for Aluminum was changed from6250 μg/mL to 6000 μg/mL after completion of this study. NMT = Not MoreThan NLT = Not Less Than

The data from the photostability evaluation above indicated that all thetest parameters met specifications thus confirming that the product wasstable even after exposure to visible and/or UV lights.

Example 9—Comparative Trace Element Compositions

This example shows currently available trace element compositions (e.g.,Multitrace®-5 concentrated) that contain zinc, copper, selenium,manganese and chromium, which is compared to the new trace elementcompositions of the current application (shown in Table 35 as *, **)that have reduced amounts of zinc, copper, manganese and no detectablechromium compared to the Multitrace®-5 concentrated.

TABLE 35 mcg/mL Composition Zinc Copper Selenium Manganese ChromiumComments Multitrace ®-5 1000 400 20 100 4 (Available from AmericanRegent) Multitrace ®-5 5000 1000 60 500 10 Concentrated (Available fromAmerican Regent) Multitrace ®-4 1000 400 NA 100 4 (Available fromAmerican Regent) Multitrace ®-4 5000 1000 NA 500 10 Concentrated(Available from American Regent) Multitrace ®-4 1000 100 NA 25 1Pediatric (Available from American Regent) Multitrace ®-4 1500 100 NA 250.85 Neonatal (Available from American Regent) ADDAMEL ™ 650 130 3.2 271 Also contains (Available Iodide (13 mcg), from Fluoride (95 mcg),Frenserdus Molybdenum Kabi) (1.9 mcg). *New 3000 300 60 55 NAcomposition Adult/Pediatric (also in Table 6) **New 1000 60 6 3 NAcomposition Neonatal

From the Table 35, the amount of selenium for the adult Multitrace®-5concentrated composition and the new adult/pediatric composition is thesame, which is 60 mcg/mL selenium. The other trace elements in the newadult/pediatric composition are zinc, copper, and manganese, which arein reduced amounts—mainly 3000 mcg/mL zinc, 300 mcg/mL copper, 55 mcg/mLmanganese, and no detectable chromium compared to the Multitrace®-5concentrated composition.

For the new neonatal composition, compared to the Multitrace®-4 neonatalcomposition, the zinc, copper, and manganese are in reducedamounts—mainly 1000 mcg/mL zinc, 60 mcg/mL copper, 3 mcg/mL manganesecompared to the Multitrace®-4 neonatal composition. However, theselenium for the new neonatal composition is 6 mcg/mL, which isincreased.

Both the new adult/pediatric composition and the new neonatalcomposition have no detectable chromium, which is unlike othercommercially available compositions (e.g., Addamel™, Multitrace®-5, andMultitrace®-4).

These new compositions are customized to about 80% of the respectiveadult/pediatric and neonatal populations that need trace elementadditions to the parenteral nutrition. For example, the newadult/pediatric trace element composition is customized for patientsabove 10 kg body weight, while the new neonatal trace elementcomposition is customized for patients under 10 kg body weight. The newadult/pediatric trace element composition and the new neonatal traceelement composition will be safer than currently available trace elementproducts.

Further, the adult/pediatric trace element composition when added to theKABIVEN® and CLINIMIX E admixtures and stored for up to 14 days underrefrigeration (2° C. to 8° C.) met the protocol's acceptance criteriaand showed stability in PN after 14 days under refrigeration asdiscussed in Examples 1-6.

Example 10—Comparative Trace Element Compositions

TABLE 36 Recommended Weight-Based Daily Dosage of Trace Element (mL) forPediatric Patients weighing 10 kg to 49 kg and Corresponding Amount ofEach Trace Element (mcg) Recommended Weight-Based Amount of TraceElement Dosage of Provided by the Corresponding Trace Element TraceElement Volume Body Weight In Volume Zinc Copper Manganese Selenium 10kg to 19 0.2 mL   600 mcg  60 mcg 11 mcg 12 mcg kg 20 kg to 29 0.4 mL1,200 mcg 120 mcg 22 mcg 24 mcg kg 30 kg to 39 0.6 mL 1,800 mcg 180 mcg33 mcg 36 mcg kg 40 kg to 49 0.8 mL 2,400 mcg 240 mcg 44 mcg 48 mcg kg

Additional Supplementation with Trace Element

For pediatric patients weighing 10 kg to 49 kg, additional zinc (inheavier patients in some weight bands), copper and selenium may beneeded to meet the recommended daily dosage of these trace elements,shown below. To determine the additional amount of supplementation thatis needed, compare the calculated daily recommended dosage based on thebody weight of the patient to the amount of each trace element providedby Trace Element (Table 36) and other dietary sources:

-   Zinc: 50 mcg/kg/day (up to 3,000 mcg/day)-   Copper: 20 mcg/kg/day (up to 300 mcg/day)-   Selenium: 2 mcg/kg/day (up to 60 mcg/day).

Example 11—Trace Elements Composition (Tralement™)

Tralement™ is indicated in adult and pediatric patients weighing atleast 10 kg as a source of zinc, copper, manganese, and selenium forparenteral nutrition when oral or enteral nutrition is not possible,insufficient, or contraindicated.

The trace element composition Tralement™ can be in a single dose vial.Each mL contains zinc about 3 mg (equivalent to zinc sulfate 7.41 mg),copper about 0.3 mg (equivalent to cupric sulfate 0.75 mg), manganeseabout 55 mcg (equivalent to manganese sulfate 151 mcg), selenium about60 mcg (equivalent to selenious acid 98 mcg), and water for injection.Sulfuric acid may be added to adjust pH between 1.5 and 3.5.

In some embodiments, the zinc used in the trace element composition canbe zinc heptahydrate having the molecular formula ZnSO₄.7H₂O and amolecular weight of 287.54 g/mol.

In some embodiments, the copper used in the trace element compositioncan be cupric sulfate that is in pentahydrate form having the molecularformula CuSO₄.5H₂O and a molecular weight of 249.69 g/mol.

In some embodiments, the manganese used in the trace element compositioncan be manganese sulfate that is in a monohydrate form having themolecular formula MnSO₄.H₂O and a molecular weight of 169.02 g/mol.

In some embodiments, the selenium in the trace element composition canbe selenious acid that has the molecular formula H₂SeO₃.H₂O and amolecular weight of 128.97 g/mol.

Example 12—Trace Elements Composition (Multrys™)

The trace elements composition (Multrys™) is indicated in neonatal andpediatric patients weighing less than 10 kg as a source of zinc, copper,manganese, and selenium for parenteral nutrition when oral or enteralnutrition is not possible, insufficient, or contraindicated.

The trace elements composition (Multrys™) can contain 4 trace elementsin a sterile, nonpyrogenic, clear, and colorless to slightly bluesolution, that can be used as a combination of four trace elements andan additive to intravenous solutions for parenteral nutrition. In thisparticular embodiment of this example, it has no preservative. Eachsingle-dose vial can contain 1 mL. *Each mL contains zinc about 1,000mcg (equivalent to zinc sulfate 2,470 mcg), copper about 60 mcg(equivalent to cupric sulfate 150 mcg), manganese about 3 mcg(equivalent to manganese sulfate 8.22 mcg), selenium about 6 mcg(equivalent to selenious acid 9.8 mcg), and water for injection.Sulfuric acid may be added to adjust pH between 1.5 and 3.5.

Zinc sulfate can be in a heptahydrate form having the molecular formula:ZnSO₄.7H₂O and molecular weight of about 287.54 g/mol. The cupricsulfate can be in a pentahydrate form having the molecular formula:CuSO₄.5H₂O and molecular weight: 249.69 g/mol. The manganese sulfate canbe in a monohydrate form and have the molecular formula: MnSO₄.H₂O andmolecular weight of about 169.02 g/mol. The selenious acid has themolecular formula: H₂SeO₃ and molecular weight of about 128.97 g/mol. Inthis particular embodiment of this example, the trace elementscomposition contains no more than 1,500 mcg/L of aluminum.

Recommended Dosage in Pediatric Patients and Monitoring Considerations

Multrys™ is a fixed-combination product. Each mL of Multrys™ provideszinc 1,000 mcg, copper 60 mcg, manganese 3 mcg, and selenium 6 mcg.

Recommended Dosage for Pediatric Patients Weighing 0.4 kg to 0.59 kg

The total recommended dosage of Multrys™ is 0.2 mL every other day.

Daily supplementation of Zinc, Copper, and Selenium will be needed tomeet daily requirements (See Table B below).

Recommended Dosage for Pediatric Patients Weighing 0.6 kg to less than10 kg

The recommended dosage of Multrys™ is 0.3 mL/kg/day rounded to nearest0.1 mL for up to a maximum of 1 mL per day.

The recommended volume of Multrys™ to be added to parenteral nutritionranges from 0.2 mL per day to 1 mL per day based on body weight, seeTable A below.

TABLE A Recommended Daily Volume of Multrys ™ and Corresponding Amountof Each Trace Element (mcg) Amount of Trace Element Provided by theCorresponding Multrys ™ Volume Recommended Zinc Copper ManganeseSelenium Body Weight Daily Volume mcg mcg mcg mcg 0.6 kg to 0.8 kg 0.2mL 200 12 0.6 1.2 0.9 kg to 1.1 kg 0.3 mL 300 18 0.9 1.8 1.2 kg to 1.4kg 0.4 mL 400 24 1.2 2.4 1.5 kg to 1.7 kg 0.5 mL 500 30 1.5 3 1.8 kg to2 kg 0.6 mL 600 36 1.8 3.6 2.1 kg to 2.3 kg 0.7 mL 700 42 2.1 4.2 2.4 kgto 2.6 kg 0.8 mL 800 48 2.4 4.8 2.7 kg to 2.9 kg 0.9 mL 900 54 2.7 5.4  3 kg to 9.9 kg   1 mL 1,000 60 3 6

Additional Trace Element Supplementation with Multrys™

Multrys™ is recommended only for pediatric patients who requiresupplementation with all four of the individual trace elements (i.e.,zinc, copper, manganese and selenium).

-   -   To determine the additional amount of supplementation that is        needed, compare the calculated daily recommended dosage based on        the body weight of the patient to the amount of each trace        element provided by Multrys™ and enteral nutrition sources.

TABLE B Daily Requirement for Trace Element Supplementation forPediatric Patients Trace Patient Weight Daily Element (kg) Requirement*Zinc Less than 3 kg 400 mcg/kg/day 3 kg to 5 kg 250 mcg/kg/day 5 to 10kg 100 mcg/kg/day Copper —  20 mcg/kg/day Selenium —  2 mcg/kg/dayManganese** —  1 mcg/kg/day *Multrys ™ is not recommended for pediatricpatients who may require a lower dosage of one or more of theseindividual trace elements. **Avoid additional manganese supplementationwith Multrys ™ use. Accumulation of manganese in the brain can occurwith long-term administration with higher than the recommended dosage of1 mcg/kg/day. For pediatric patients weighing less than 3 kg, Multrys ™does not provide the recommended daily dosage of zinc. Zinc: Forpatients weighing less than 3 kg, add Zinc Sulfate to provide totaldaily recommended dose of 400 mcg/kg/day using parenteral and/or enteralroutes of administration. For pediatric patients weighing 0.4 kg to 0.59kg and 4 kg to 9.9 kg, Multrys ™ does not provide the recommended dailydosage of copper or selenium. Copper: For patients weighing 0.4 to 0.59kg or 4 kg to 9.9 kg, add Cupric Chloride to provide total dailyrecommended dose of 20 mcg/kg/day using parenteral and/or enteral routesof administration. Selenium: For patients weighing 0.4 to 0.59 kg or 4kg to 9.9 kg, add Selenious Acid to provide total daily recommended doseof 2 mcg/kg/day using parenteral and/or enteral routes ofadministration.

Monitoring

Monitor zinc, copper, and selenium serum concentrations and manganesewhole blood concentrations during long-term administration of parenteralnutrition.

Low Chromium

In some embodiments, the amount of chromium in the parenteral nutritioncontaining the trace elements composition (e.g., Multrys™ or Tralement™)or the trace elements composition (e.g., Multrys™ or Tralement™) itselfis not more than about 0.15 μg/mL to not more than about 0.07 μg/mL orlower. With the not more than about 0.15 μg/mL of chromium, the maximumpotential exposure to chromium (e.g., 0.045 μg/kg/day) will be 22.5% ofthe maximum chromium dose that can be used for parenteral nutrition in atarget patient population (e.g., children (weighing 0.4-9.9 kg)). Thiscan be based on a target dose volume of, for example, 0.3 mL/kg/day. Insome embodiments, this will reduce the risk of toxicity from totalchromium exposure in the parenteral nutrition (e.g., from intentionallyadded chromium and chromium as an impurity).

It will be apparent to those skilled in the art that variousmodifications and variations can be made to various embodimentsdescribed herein without departing from the spirit or scope of theteachings herein. Thus, it is intended that various embodiments coverother modifications and variations of various embodiments within thescope of the present teachings. Since modifications will be apparent tothose of skill in the art, it is intended that this disclosure belimited only by the scope of the appended claims.

What is claimed is:
 1. An injectable composition comprising water, about60 μg of selenium, 3,000 μg of zinc, about 300 μg of copper, and about55 μg of manganese per 1 mL of the injectable composition, wherein theinjectable composition contains 0 μg per 1 mL to about 10 μg per 1 mL ofiron, does not contain any vitamins, contains no added chromium and noaluminum or aluminum in an amount not to exceed 6 μg per 1 mL of theinjectable composition.
 2. The injectable composition of claim 1,wherein the injectable composition comprises 3,000 μg of zinc, 300 μg ofcopper, 60 μg of selenium, and 55 μg of manganese per 1 mL of theinjectable composition.
 3. The injectable composition of claim 1,further comprising (i) silicon from about 0.0001 to about 100 μg/mL,magnesium from about 0.0001 to about 50 μg/mL, calcium from about 0.0001to about 50 μg/mL, boron from about 0.0001 to about 50 μg/mL or amixture thereof; (ii) silicon from about 0 to about 100 μg/mL, magnesiumfrom about 0 to about 50 μg/mL, calcium from about 0 to about 50 μg/mL,boron from about 0 to about 50 μg/mL or a mixture thereof; or (iii)wherein the zinc is elemental zinc, the copper is elemental copper, theselenium is elemental selenium, the manganese is elemental manganese andthe water is sterile water for injection.
 4. The injectable compositionof claim 1, wherein the composition has a pH of about 1.0 to about 5 andthe injectable composition is for use in adult or pediatric humanpatients.
 5. The injectable composition of claim 4, wherein thecomposition further comprises a pH adjusting agent to adjust the pH. 6.The injectable composition of claim 1, wherein the injectablecomposition is at least one of a preservative-free composition, asterile composition, or a ready-to-use injectable aqueous composition.7. The injectable composition of claim 1, wherein the injectablecomposition comprises a preservative.
 8. The injectable composition ofclaim 7, wherein the preservative comprises benzyl alcohol in an amountof 0.9% by weight based on a total weight of the injectable composition.9. The injectable composition of claim 2, wherein the zinc is elementalzinc from zinc sulfate or zinc sulfate heptahydrate, the copper iselemental copper from cupric sulfate or cupric sulfate pentahydrate, themanganese is elemental manganese from manganese sulfate or manganesesulfate monohydrate and the selenium is elemental selenium fromselenious acid.
 10. The injectable composition of claim 1, wherein theinjectable composition is in a multi-dose vial.
 11. The injectablecomposition of claim 10, wherein the multi-dose vial contains 10 mL ofthe injectable composition.
 12. The injectable composition of claim 1,wherein the injectable composition contains about 0.0001 μg/mL to about0.25 μg/mL of chromium as an impurity.
 13. The injectable composition ofclaim 1, wherein the injectable composition contains about 1 ppm toabout 6 μg/mL of aluminum as an impurity.
 14. The injectable compositionof claim 1, wherein the zinc is zinc sulfate heptahydrate at a dose ofabout 2.5 to about 7 mg/day, the copper is cupric sulfate pentahydrateat a dose of about 0.3 to about 1.5 mg/day, the manganese is manganesesulfate monohydrate at a dose of about 0.015 to about 0.08 mg/day, andthe selenium is selenious acid at a dose of about 20 to about 60 μg/day.15. An injectable trace element composition comprising water, and as theactive ingredients about 7.41 mg of zinc sulfate or zinc sulfateheptahydrate, about 0.75 mg of cupric sulfate or cupric sulfatepentahydrate, about 151 mcg of manganese sulfate or manganese sulfatemonohydrate and about 98 mcg of selenious acid per 1 mL of theinjectable composition, wherein the injectable composition containsimpurities of chromium, aluminum, and iron, wherein the impurities arechromium in an amount not to exceed 1 μg, aluminum in an amount not toexceed 6 μg, and 0 μg to about 10 μg of the iron per 1 mL of theinjectable composition.
 16. The injectable composition of claim 1,wherein the injectable composition is in a vial.
 17. The injectablecomposition of claim 1, wherein the zinc, copper, selenium, manganeseare in elemental or salt form.
 18. The injectable composition of claim5, wherein the pH adjusting agent is at least sodium hydroxide orsulfuric acid.
 19. The injectable composition of claim 1, wherein theinjectable composition contains less than about 0.25 μg/mL of chromiumas an impurity.
 20. The injectable composition of claim 1, whereinpermitted daily limits (PDL) of the injectable composition do not exceedabout 0.4 μg/day of cadmium, about 0.5 μg/day of lead, about 1.5 μg/dayof arsenic, about 0.4 μg/day of mercury, about 1 μg/day of cobalt, about2 μg/day of vanadium, about 4 μg/day of nickel, about 1.6 μg/day ofthallium, about 20 μg/day of gold, about 2 μg/day of palladium, about 2μg/ day of iridium, about 2 μg/day of osmium, about 2 ug/day of rhodium,about 2 μg/day of ruthenium, about 2 μg/day of silver, about 2 ug/day ofplatinum, about 50 ug/day of lithium, about 18 μg/day of antimony, about140 μg/day of barium, about 300 μg/day of molybdenum, about 120 μg/ dayof tin, about 1 μg/day of chromium, about 6 μg/day of aluminum, about 50μg/day of boron, about 50 μg/day of calcium, about 10 μg/day of iron,about 94,000 μg/day of potassium, about 50 μg/day of magnesium, about24,000 μg/day of sodium, about 1 μg/day of tungsten, and/or about 100μg/day of silicon.
 21. The injectable composition of claim 1, whereinthe injectable composition contains chromium in an amount not to exceed1 μg per 1 mL of the injectable composition and the injectablecomposition contains aluminum in an amount not to exceed 6 μg per 1 mLof the injectable composition.
 22. The injectable composition of claim15, wherein the injectable composition contains no chromium and theinjectable composition contains no aluminum.
 23. An injectablecomposition comprising water, active ingredients comprising about 60 μgof selenium, about 3,000 μg of zinc, about 300 μg of copper, and about55 μg of manganese per 1 mL of the injectable composition, andimpurities of chromium, aluminum, and iron, wherein the impurities arechromium in an amount not to exceed 1 μg, aluminum in an amount not toexceed 6 μg, and 0 μg to about 10 μg of the iron per 1 mL of theinjectable composition.
 24. An injectable composition comprising water,and active ingredients, the active ingredients consisting of about 60 μgof selenium, about 3,000 μg of zinc, about 300 μg of copper, and about55 μg of manganese per 1 mL of the injectable composition.
 25. Theinjectable composition of claim 24, wherein the active ingredientsconsists of 60 μg of selenium, 3,000 μg of zinc, 300 μg of copper, and55 μg of manganese per 1 mL of the injectable composition.
 26. Aninjectable composition comprising water, about 6 μg of selenium, about1,000 μg of zinc, about 60 μg of copper, and about 3 μg of manganese per1 mL of the injectable composition, wherein the injectable compositioncontains 0 μg per 1 mL to about 10 μg per 1 mL of iron, does not containany vitamins, contains no added chromium and no aluminum or aluminum inan amount not to exceed 6 μg per 1 mL of the injectable composition. 27.An injectable composition comprising water, active ingredientscomprising about 6 μg of selenium, about 1,000 μg of zinc, about 60 μgof copper, and about 3 μg of manganese per 1 mL of the injectablecomposition, and impurities of chromium, aluminum, and iron, wherein theimpurities are chromium in an amount not to exceed 1 μg, aluminum in anamount not to exceed 6 μg, and 0 μg to about 10 μg of the iron per 1 mLof the injectable composition.
 28. The injectable composition of claim27, wherein the injectable composition comprises 1000 μg of zinc, 60 μgof copper, 6 μg of selenium and 3 μg of manganese per 1 mL of injectablecomposition.
 29. An injectable composition comprising water, and activeingredients, the active ingredients consisting of about 6 μg ofselenium, about 1,000 μg of zinc, about 60 μg of copper, and about 3 μgof manganese per 1 mL of the injectable composition.
 30. The injectablecomposition of claim 29, wherein the active ingredients consist of 6 μgof selenium, 1,000 μg of zinc, 60 μg of copper, and 3 μg of manganeseper 1 mL of the injectable composition.
 31. An injectable compositioncomprising water, and active ingredients, the active ingredientsconsisting of about 2,470 mcg of zinc sulfate or zinc sulfateheptahydrate, about 150 mcg of cupric sulfate or cupric sulfatepentahydrate, about 8.22 mcg of manganese sulfate or manganese sulfatemonohydrate and about 9.8 mcg of selenious acid per 1 mL of theinjectable composition.
 32. The injectable composition of claim 31,wherein the active ingredients consist of 2,470 mcg of zinc sulfate orzinc sulfate heptahydrate, 150 mcg of cupric sulfate or cupric sulfatepentahydrate, 8.22 mcg of manganese sulfate or manganese sulfatemonohydrate and 9.8 mcg of selenious acid per 1 mL of the injectablecomposition.
 33. The injectable composition of claim 31, wherein theinjectable composition comprises sodium hydroxide or sulfuric acid as apH adjusting agent.
 34. An injectable composition comprising water, andactive ingredients, the active ingredients consisting of about 7.41 mgof zinc sulfate or zinc sulfate heptahydrate, about 0.75 mg of cupricsulfate or cupric sulfate pentahydrate, about 151 mcg of manganesesulfate or manganese sulfate monohydrate and about 98 mcg of seleniousacid per 1 mL of the injectable composition.
 35. The injectablecomposition of claim 34, wherein the active ingredients consist of 7.41mg of zinc sulfate or zinc sulfate heptahydrate, 0.75 mg of cupricsulfate or cupric sulfate pentahydrate, 151 mcg of manganese sulfate ormanganese sulfate monohydrate and 98 mcg of selenious acid per 1 mL ofthe injectable composition.
 36. The injectable composition of claim 34,wherein the injectable composition comprises sodium hydroxide orsulfuric acid as a pH adjusting agent.
 37. The injectable composition ofclaim 1, wherein the chromium is elemental chromium from chromiumchloride.
 38. The injectable composition of claim 26, wherein thechromium is elemental chromium from chromium chloride.
 39. Theinjectable composition of claim 26, wherein the injectable compositionis for use in pediatric or neonatal human patients.
 40. The injectablecomposition of claim 1, wherein the injectable composition is for use inadult or pediatric human patients.
 41. The injectable composition ofclaim 17, wherein the ratio of elemental copper to elemental zinc is1:10.
 42. The injectable composition of claim 26, wherein the zinc iselemental zinc, the copper is elemental copper, the manganese iselemental manganese and the selenium is elemental selenium.
 43. Theinjectable composition of claim 42, wherein the ratio of elementalselenium to elemental copper is 1:10.
 44. The injectable composition ofclaim 4, wherein the injectable composition comprises a siliconimpurity.
 45. The injectable composition of claim 4, wherein theinjectable composition is in a glass vial or ampule and has a siliconimpurity in an amount of not more than 100 μg/mL.
 46. The injectablecomposition of claim 1, wherein the injectable composition is stable forup to two years.
 47. The injectable composition of claim 26, wherein theinjectable composition is stable for up to two years.
 48. The injectablecomposition of claim 1, wherein the injectable composition has abacterial endotoxin limit of not more than 50 EU/mL.
 49. The injectablecomposition of claim 26, wherein the injectable composition has abacterial endotoxin limit of less than 17.50 EU/mL.
 50. The injectablecomposition of claim 26, wherein the injectable composition comprises1000 μg of zinc, 60 μg of copper, 6 μg of selenium and 3 μg of manganeseper 1 mL of injectable composition.
 51. The injectable composition ofclaim 23, wherein the injectable composition comprises 3,000 μg of zinc,300 μg of copper, 60 μg of selenium, and 55 μg of manganese per 1 mL ofthe injectable composition.
 52. The injectable composition of claim 23,wherein the zinc is elemental zinc from zinc sulfate or zinc sulfateheptahydrate, the copper is elemental copper from cupric sulfate orcupric sulfate pentahydrate, the manganese is elemental manganese frommanganese sulfate or manganese sulfate monohydrate and the selenium iselemental selenium from selenious acid.
 53. The injectable compositionof claim 26, wherein the zinc is elemental zinc from zinc sulfate orzinc sulfate heptahydrate, the copper is elemental copper from cupricsulfate or cupric sulfate pentahydrate, the manganese is elementalmanganese from manganese sulfate or manganese sulfate monohydrate andthe selenium is elemental selenium from selenious acid.
 54. Theinjectable composition of claim 26, wherein the injectable compositionis in a vial.
 55. The injectable composition of claim 15, wherein theinjectable composition is for use in adult or pediatric human patients.56. The injectable composition of claim 23, wherein the injectablecomposition is for use in adult or pediatric human patients.
 57. Theinjectable composition of claim 27, wherein the injectable compositionis for use in pediatric or neonatal human patients.
 58. The injectablecomposition of claim 31, wherein the injectable composition is for usein pediatric or neonatal human patients.